THE  TREATMENT  OF  ACUTE 
INFECTIOUS  DISEASES 


THE  MACMILLAN  COMPANY 

NEW   YORK   •    BOSTON   •    CHICAGO    •   DALLAS 
ATLANTA    •   SAN   FRANCISCO 

MACMILLAN  &  CO.,  LIMITED 

LONDON    •   BOMBAY    •  CALCUTTA 
MELBOURNE 

THE  MACMILLAN  CO.  OF  CANADA,  LTD. 

TORONTO 


THE  TREATMENT  OF  ACUTE 
INFECTIOUS  DISEASES 


BY 
FRANK  SHERMAN  MEARA,  M.  D.,  PH.D. 

Professor  of  Clinical  Medicine  and  formerly  Professor  of  Therapeutics  in  the  Cornell 
University  Medical  College  in  New  York  City.     Consulting  Physician  to  Bellevue 
Hospital,  New  York;   to   the   Mountainside  Hospital,  Montclair,  N.  J.;  to 
the  Morristown   Memorial   Hospital,  Morristown,   N.  J.;  to  Overlook 
Hospital,   Summit,    N.    J.;    to    Dover    General    Hospital,    Dover, 
N.    J.;  Mount  Vernon  Hospital,  Mount  Vernon,  N.  Y.;  Law- 
rence  Hospital,     Bronxville,    N.   Y.;  Associate  Attending 
Physician   to  St.   Luke's   Hospital,    New  York    City 


SECOND  EDITION,  REVISED 


fork 

THE  MACMILLAN  COMPANY 
1921 

All  rights  reserved 


COPYBIQHT,  1916  and  1921 
BY  THE  MACMILLAN  COMPANY 


Set  up  and  printed.    Published  January,  1916. 
Reprinted  with  corrections,  August,  1916; 

September,  1917. 

Second  Edition  completely  revised  and  reset 
Published,  June,  1921. 


Printed  in  the  United  States  of  America 


To  the  memory  of  my  father 

SHERMAN  T.   MEARA 

whose   encouragement  was  my  inspiration 

this  book  is  dedicated 


443446 


PREFACE  TO  THE  SECOND  EDITION 

IN  the  revision  of  a  book  on  Acute  Infectious  Diseases  a  review  of 
the  literature  on  the  recent  epidemic  of  influenza,  as  well  as  the  camp 
epidemics  of  measles,  streptococcus  pneumonia,  meningitis  and  other 
infectious  processes  treated  in  this  book,  entails  a  task  of  no  inconsid- 
erable magnitude. 

It  is  hoped  that  these  subjects  will  be  found  brought  quite  up  to 
date.  Moreover,  it  has  seemed  wise  to  include  the  more  common 
acute  infections  of  the  respiratory  tract,  coryza,  tonsillitis,  laryngitis,  and 
tracheo-bronchitis,  and  to  add  a  chapter  on  acute  pleurisy;  furthermore, 
two  clinical  complexes  recently  brought  to  our  attention,  the  one  prob- 
ably incident  upon  the  influenza  epidemic,  the  other  consequent  upon 
military  operations,  encephalitis  lethargica  and  trench  fever  have  been 
added  and  for  the  sake  of  completeness  two  less  commonly  encountered 
infections  that  have  been  the  object  of  much  careful  research  work,  rat- 
bite  fever  and  Rocky  Mountain  spotted  fever.  It  has  been  deemed 
advisable  to  retain  the  chapter  on  Grip  as  written.  It  covers  a  picture 
seen  each  winter  as  the  result  of  an  acute  infection  from  one  of  several 
organisms  but  does  not  adequately  present  epidemic  influenza.  For 
this  reason  a  new  chapter  has  been  devoted  to  the  latter. 

As  a  result  of  the  camp  epidemics  of  measles,  streptococcus  pneumonia 
has  been  studied  as  never  before  and  it  has  been  deemed  proper  to 
consider  this  apart  from  pneumococcus  pneumonia. 

It  gives  me  great  pleasure  to  acknowledge  here  my  indebtedness  to 
Prof.  Oscar  W.  Bethea  of  Tulane  University,  whose  great  courtesy, 
kindly  criticisms,  and  helpful  suggestions  have  contributed  much  of 
value  to  this  revision. 

My  thanks  are  further  due  to  my  assistant,  Dr.  Connie  M.  Guion, 
without  whose  intelligent  cooperation,  the  completion  of  my  task 
would  have  been  still  longer  delayed  and  to  the  fidelity  and  tireless 
devotion  of  my  secretary,  Mrs.  Mary  Nielsen.  Finally  I  have  to  express 
my  appreciation  to  the  helpfulness  of  Dr.  Minor  B.  Hill  for  his  article  on 
Intubation,  to  Dr.  Alfred  S.  Taylor  for  his  treatise  on  empyema  and  to 
Dr.  William  Parks,  Dr.  Malcolm  Goodridge  and  Dr.  Arthur  W.  Bingham 
for  many  helpful  suggestions. 

The  kindly  letters  of  many  friends  have  been  a  compensation  for  the 
efforts  already  expended  on  this  work  and  a  stimulus  for  the  added 
labor  of  revision. 

F.  S.  M. 


PREFACE  TO  FIRST  EDITION 

To  the  layman  the  word  " physician"  connotes  a  therapeutist; 
one  whose  professional  end  and  aim  it  is  to  cure  the  sick.  If  he  thinks 
of  the  physician  at  all  as  a  student  of  the  science  of  medicine  or  as  a 
diagnostician  it  is  only  in  the  sense  that  he  is  busied  with  matters  that 
shall  lead  to  the  prevention,  cure  or  alleviation  of  disease;  and  yet 
every  practitioner  of  medicine,  seeking  assistance  in  the  exercise  of  his 
art,  feels  the  disproportion  of  the  much  that  is  offered  him  of  the  cause, 
the  course  and  the  consequences  of  disease  and  the  little  that  is  afforded 
of  the  practical  application  of  this  knowledge  to  its  legitimate  uses, 
getting  the  sick  man  well.  As  a  teacher  of  therapeutics  I  have  always 
felt  that  this  branch  of  medicine  has  been  unduly  neglected  both  in  the 
college  curriculum  and  in  the  text-book.  With  the  text-book  my  ex- 
perience has  been  that  it  either  speaks  in  generalities  assuming  knowl- 
edge on  the  part  of  the  student  or  physician,  when  such  an  assumption 
should  annul  its  very  reason  for  being,  or  it  catalogues  and  compiles 
endless  measures  and  procedures  without  effort  to  exercise  a  judgment 
of  their  relative  values.  The  few  exceptions  to  this  statement  make 
themselves  conspicuous. 

Successfully  or  not,  it  has  been  the  attempt  of  the  author  to  avoid 
these  extremes  of  error. 

Each  chapter  has  been  made  to  deal  with  an  individual  disease  in 
a  thoroughly  practical  manner;  each  little  detail  of  procedure  being 
explained  so  that  the  reader  may  actually  apply  it.  Moreover,  the 
reason  for  the  procedure,  as  based  on  our  latest  information,  both 
with  respect  to  physical  therapy  and  drugs,  the  author  has  sought  to 
give. 

Constant  and  confusing  reference  to  the  literature  has  been  avoided, 
but  an  effort  to  give  due  credit  has  been  made. 

The  book,  finally,  must  be  looked  on  as  an  expression  of  the  author's 
individual  opinion  and  will  be  didactic  rather  than  critical. 

A  summary  at  the  end  of  each  chapter  is  designed  to  add  to  its  use- 
fulness as  a  ready  reference  for  the  busy  practitioner  and  as  a  review 
to  the  student. 

F.  S.  M. 


CONTENTS 

CHAPTER  PAGE 

I    FEBRILE  CONDITIONS 1 

II    DIET  IN  ACUTE  INFECTIOUS  DISEASES 10 

III    ACUTE  RHEUMATIC  FEVER 30 

•IV    ACUTE  RHINITIS 71 

V    TONSILLITIS  AND  VINCENT'S  ANGINA 80 

VI    ACUTE  LARYNGITIS 94 

VII    ACUTE  BRONCHITIS  AND  TRACHEITIS 101 

VIII    PLEURISY  (PLEURITIS) 112 

IX    PNEUMONIA 128 

X    STREPTOCOCCUS  PNEUMONIA 208 

XI    THE  TREATMENT  OF  GRIP  OR  SPORADIC  INFLUENZA 216 

XII    EPIDEMIC  INFLUENZA 235 

XIII  ENCEPHALITIS  LETHARGICA 271 

XIV  TYPHOID  AND  PARATYPHOID  FEVERS 277 

XV    MALARIA 322 

XVI    DYSENTERY — BACILLARY  AND  AMEBIC 353 

XVII    SCARLET  FEVER 387 

XVIII    DIPHTHERIA 443 

XIX    MEASLES 487 

XX    RUBELLA  (GERMAN  MEASLES) 512 

XXI    VARICELLA  (CHICKEN  Pox) 514 

XXII    PERTUSSIS  (WHOOPING  COUGH) 520 

XXIII  MUMPS  (PAROTITIS) 545 

XXIV  GLANDULAR  FEVER 555 

XXV    CEREBRO-SPINAL  MENINGITIS ; 560 

XXVI    POLIOMYELITIS  (INFANTILE  PARALYSIS) 590 

XXVII    SMALL  Pox  (VARIOLA) 608 

XXVIII    TYPHUS  FEVER 625 

XXIX    PLAGUE 634 

XXX    DENGUE 641 

XXXI    ASIATIC  CHOLERA 646 

XXXII    MALTA  FEVER 656 

XXXIII  ROCKY  MOUNTAIN  SPOTTED  FEVER 664 

XXXIV  LEPROSY 670 

XXXV    ANTHRAX 678 

XXXVI    GLANDERS  OR  FARCY 687 

XXXVII    FOOT  AND  MOUTH  DISEASE 693 

XXXVIII    PSITTACOSIS 698 

XXXIX    RABIES 699 

XL    TETANUS 711 

XLI    INFECTIOUS  JAUNDICE  (WEIL'S  DISEASE) 728 

XLII    YELLOW  FEVER 735 

XLIII    RAT-BITE  FEVER 744 

XLIV    TRENCH  FEVER 751 

XLV    SEPTICAEMIA  AND  PY^MIA 757 

XLVI    ERYSIPELAS 772 

INDEX.  .  781 


THE  TREATMENT  OF  ACUTE 
INFECTIOUS  DISEASES 


TREATMENT    OF   ACUTE    INFECTIOUS 

DISEASES 

CHAPTER  I 

FEBRILE  CONDITIONS 
GENERAL  PRINCIPLES 

IT  is  one  of  the  most  hopeful  features  of  modern  therapy  that  it  is 
taking  cognizance  of  the  fact  that  the  organism  has  been  perfecting 
means  of  defense  since  first  it  became  the  seat  of  disease  and  that  these 
means  of  defense  are  to  be  read  not  merely  in  the  subtile  elaboration  of 
antitoxic  bodies  in  the  tissues  and  the  marshalling  of  counter-forces 
in  the  blood  elements,  but  also  in  the  alteration  of  the  functions  of  organs. 
Emesis  as  a  symptom  is  primarily  an  effort  to  unburden  the  stomach  of 
deleterious  substances;  diarrhea  is  protective  in  the  same  sense;  cough 
removes  secretions  which  are  both  irritants  and  mechanical  impediments 
to  the  respiration;  pain  ensures  rest  to  an  affected  part  and  so  on.  Inter- 
ference with  these  symptoms  must  be  undertaken  with  discretion  lest  it 
become  pernicious.  It  is  the  knowledge  of  when  to  let  alone  and  when  to 
interfere  that  constitutes  the  art  of  therapy.  Emesis,  diarrhea  and  cough 
may  become  a  source  of  exhaustion;  pain  which  has  pointed  the  way 
to  the  trouble  and  hinted  the  need  of  rest  be  illy  borne  when  continued 
and  fever  rise  to  degrees  that  are  incompatible  with  its  purpose  and 
constitute  hyperpyrexia.  At  this  point,  treatment  steps  in  to  modify 
and  assist,  not  to  disregard  Nature's  signals. 

Fever,  as  the  physician  knows  it,  is  almost  invariably  the  result 
of  bacterial  action,  so  cannot  be  dissociated  from  toxemia;  but  pyrexia 
and  toxemia  show  but  little  parallelism;  indeed,  the  worst  forms  of 
toxemia  may  be  accompanied  by  no  pyrexia  at  all,  while  a  relatively 
high  temperature  may  be  seen  with  a  minimal  toxemia.  Briefly,  then, 
unless  the  degree  of  temperature  is  inordinately  high,  that  is,  constitutes 
a  hyperpyrexia,  the  treatment  of  fever  is  not  an  antipyretic  treatment 
but  an  antitoxemic  treatment,  and  such  fall  of  temperature  as  accom- 
panies our  efforts  is  incidental  to  them  and  not  the  object  at  which  we 
aimed. 

The  treatment  of  fever  involves  the  appreciation  of  certain  broad 
principles  that  in  the  main  are  physiological.  They  are  not  numer- 


2  TREATMENT  OF  ACUTE  INFECTIOUS  DISEASES 

ous,  'but  they  are  of  fundamental  importance.  We  shall  take  them 
up  seriatim.  (1)  rest;  (2)  diet,  including  the  ingestion  of  water; 
(3)  fresh  air;  (4)  water  locally  applied,  that  is  hydrotherapy ; 
(5)  drugs ;  (6)  hyperpyrexia.  I  think  it  little  masters  what  name  we 
give  the  febrile  process  or  the  organism  inducing  it.  The  procedures 
are  much  the  same. 

Rest.  It  is  a  valuable  form  of  mental  exercise  for  a  physician  to 
pause  occasionally  and  review  some  of  the  fundamental  facts  of  phys- 
iology that  are  relevant  to  the  problem  in  hand.  First  one  should 
recall  the  fact  that  the  sum  total  of  the  body's  activities  are  but  the 
expression  of  the  conversion  of  potential  energy  of  the  foodstuffs  into 
these  different  forms  of  energies;  that  the  body  observes  an  accurate 
balance  between  the  intake  and  output;  that  the  law  of  conservation 
of  energy  obtains  in  the  human  body  as  well  as  elsewhere,  and,  therefore, 
when  the  intake  is  lessened,  the  expenditure  should  be  diminished  and 
useless  forms  of  work  should  be  avoided  that  useful  purposes  may  be 
subserved. 

All  this  means  that  in  fever  rest  is  imperative  and  that,  as  the  body 
cells  are  expending  energy  in  the  elaboration  of  protective  substances 
and  the  processes  of  repair  are  active  in  inflamed  tissues,  muscular 
unrest  and  muscular  work  should  be  avoided.  Physiologists  tell  us  that 
carbon  dioxide,  an  end  product  of  the  combustion  of  foodstuffs  in  the 
production  of  energy,  may  be  taken  as  a  measure  of  the  energy  of  work 
and  heat  arising  in  the  body  and  that  the  same  man  who  during  sleep 
eliminates  22  grams  of  carbon  dioxide  an  hour  will,  when  awake  and 
exercising  the  greatest  amount  of  muscular  relaxation  possible,  eliminate 
31  grams,  and  under  conditions  that  we  ordinarily  term  rest,  such  as 
most  patients  observe,  eliminates  38  grams.  These  figures  are  cited  to 
call  attention  to  what  a  relative  term  "rest"  is. 

Again,  in  febrile  conditions,  the  vascular  and  other  vital  centres  are 
all  too  often  sought  out  and  when  we  recall  the  lessened  number  of  heart 
beats  in  recumbency  and  slight  fall  of  pressure  under  the  same  circum- 
stances we  appreciate  the  economy  exerted  in  behalf  of  these  organs  by 
rest. 

Rest  means  something  more  than  going  to  bed,  though  that 
is  imperative.  It  means  that  the  bed  must  be  comfortable,  so  that 
energy  shall  not  be  wasted  in  the  effort  to  maintain  strained  positions 
or  avoid  uncomfortable  ones;  it  means  competent  nursing;  it  means 
measures  directed  at  sleeplessness  and  at  delirium.  Mental  rest  is 
equally  important,  for  though  the  loss  of  energy  in  the  mental  proc- 
esses per  se  is  minute,  strained  and  restless  muscles  are  the  results  of 
anxiety  and  concern,  as,  indeed,  are  perverted  functions  in  many  or- 


FEBRILE  CONDITIONS  3 

gans.  Leave  the  sick  room  to  the  sick;  exclude  solicitous  friends,  Job's 
comforters,  mourners  before  the  fact.  Avoid  the  introduction  of  busi- 
ness matters  or  domestic  concerns,  and  let  quiet  and  order  reign.  The 
contrast  between  a  well-ordered,  neat,  cool,  sick-room,  and  a  hot  stuffy 
room  with  six  to  ten  visitors,  gas-jets  in  full  action  and  Babel  and  Chaos 
regnant  is  one  of  the  most  striking  that  can  be  witnessed. 

Diet.  See  Chap.  II,  Diet  in  Acute  Infectious  Disease.  Again  let 
us  appeal  to  physiology  for  facts.  They  are  (1)  That  the  amount  of 
work  done  and  the  amount  of  heat  given  off  by  the  human  body  each 
day  is  derived  from  the  food  taken  in  that  day  or  stored  in  the  body 
from  previous  meals  and  that  that  store  is  not  inexhaustible.  (2)  That 
the  amount  of  energy  demanded  by  a  man  at  rest  each  day  amounts 
on  the  average  to  33  calories  l  per  kilo  of  body  weight  which  in  a  man 
of  average  weight  amounts  to  2,300  calories.  (3)  That  a  sick  man  at 
rest  requires  as  many  calories  of  energy  as  a  well  man.  (4)  That  fever 
makes  certain  demands  in  excess  of  those  obtaining  in  health,  because 
the  increased  temperature  per  se,  that  is,  pyrexia  above  102°  F.  increases 
the  output  some  25  per  cent,  on  an  average,  thus  raising  our  caloric 
requirements  to  40  per  kilo  or  about  2,800  for  the  man  of  average  weight. 
(5)  That  the  toxins  of  disease  are  destructive  of  body  tissue  in  varying 
degrees,  a  destruction  which  may  be  overcome  or  minimized  by  a  suffi- 
cient intake  of  food.  (6)  That  the  amount  of  protein  needed  each  day  in 
health  is  about  100  grams.  (7)  That  in  fever  the  requirement  is  about 
the  same  or  may  be  a  trifle  less,  75  to  85  grams,  which  is  enough  to 
prevent  protein  loss  when  enough  carbohydrates  are  added.  The  ap- 
preciation of  these  facts  is  increasingly  important  in  the  prolonged 
fevers,  such  as  typhoid,  certain  bronchopneumonias  or  septic  conditions. 

One  other  fact  is  of  special  importance  in  orientating  us  correctly 
with  reference  to  this  subject;  namely,  that  such  studies  as  have  been 
undertaken  to  determine  the  efficiency  of  the  processes  of  digestion 
and  assimilation  of  the  foodstuffs  in  fever  show  that,  except  at  the 
onset,  these  processes  are  scarcely  unpaired. 

Briefly,  in  the  beginning  of  fever,  do  not  push  the  food;  respect  the 
meaning  of  anorexia;  but  later  increase  daily  to  the  approximation  of 
theoretical  needs.  Remember  that  there  are  other  foods  than  milk 
that  are  easily  digested,  including  cereals,  bread,  butter,  eggs. 

Water  is  an  important  item  in  the  treatment  of  fever;  all  the  water 
that  the  patient  wants  and  his  wants  should  be  determined  by  offering 
him  water  at  frequent  intervals,  as  his  cerebral  condition  may  be  such  as 
to  prevent  him  asking  for  the  amount  he  needs. 

1  This  calorie  is  the  large  calorie  and  is  that  amount  of  heat  that  will  raise  one 
kilo  of  water  through  1°  C. 


4  TREATMENT  OF  ACUTE  INFECTIOUS  DISEASES 

Studies  of  the  water  intake  in  certain  infections  such  as  pneumonia 
show  that  the  amounts  are  sometimes  extraordinary,  3,000  to  5,000  c.c. 
a  day,  and  that  the  patients  who  are  given  a  sufficiency  seem  to  do  best. 

Fresh  Air.  That  the  sick  require  fresh  air  would  seem  a  thesis  too 
simple  to  require  emphasis,  and  yet  many  physicians  make  no  protest 
against  the  vitiation  of  the  sick  room  by  a  swarm  of  visitors  and  burning 
gas-jets  and  make  only  a  half-hearted  appeal  for  an  open  window. 

The  bad  effects  of  ill  ventilation  are  due  in  part  to  the  accumulation 
of  carbon  dioxide  gas.  In  the  country  pure  air  contains  about  3  volumes 
of  the  gas  to  10,000  volumes  of  air.  In  rooms  and  work-shops  it  may  rise 
to  over  30  volumes,  and  in  the  night  with  the  gas  burning  to  nearly  50. 

We  consider  it  niggardly  in  the  hospital  if  we  do  not  allow  1,000 
cubic  feet  to  each  sick  infant,  but  how  many  of  our  patients  get  1,000 
cubic  feet  of  fresh  air  to  themselves  in  the  sick  room? 

The  increase  of  carbon  dioxide  is  not  the  only  evil  in  ill  ventilation,  for 
contamination  of  the  air  with  bacteria  and  varied  forms  of  dirt  must 
ensue;  while  heat,  moisture,  or  stagnation  and  odors  add  their  depressing 
effects. 

But  there  is  another  quality  to  fresh  air  when  taken  in  the  open 
that  adds  materially  to  its  value;  it  is  the  element  of  cold  given  either 
by  the  temperature  of  the  air  or  by  the  effects  of  its  movement.  Pem- 
brey,  in  a  masterly  article  on  Respiratory  Exchange  in  Hill's  Recent 
Advances  in  Physiology  and  Biochemistry,  says,  "The  success  of  the 
open-air  treatment  depends  it  would  seem,  not  so  much  upon  any  greater 
purity  of  the  air  as  upon  free  exposure;  the  open  air  increases  the  combus- 
tion and  respiratory  exchange  improves  the  appetite  and  augments  the 
metabolism." 

More  than  that,  it  is  an  every-day  demonstration  to  the  students 
in  our  ward  that  the  exposure  of  the  febrile  patient  to  the  open,  cold, 
clear  air  will  induce  a  rise  of  blood  pressure  over  that  obtained  in  a 
well-ventilated  ward  equal  to  or  better  than  that  obtained  from  our 
usual  vasomotor  stimulants,  with  the  added  advantage  of  being  con- 
tinuously sustained  which  does  not  obtain  with  the  drugs. 

I  am  convinced  of  the  very  great  value  of  the  open  air  treatment 
of  fever.  The  pulse  and  respiration  improve,  the  cerebral  intoxication 
diminishes  and  the  patients  are  almost  universal  in  their  commenda- 
tion of  it. 

To  reap  success,  however,  the  technique  must  be  correct.  The  pa- 
tient's bed  must  be  so  made  as  to  keep  the  body  always  warm,  by  en- 
closing the  bed  in  impermeable  material  like  rubber  sheeting  or  paper, 
the  use  of  the  hot  water  bottle,  and  by  sheltering  from  winds.  The 
good  effects,  I  believe,  come  from  the  action  of  cold  on  the  nerves  of  the 


FEBRILE  CONDITIONS  5 

mucous  membrane  of  the  nose  or  of  the  face,  producing  reflexly  an 
improved  vascular  condition. 

Water  Locally  Applied,  Hydrotherapy.  I  am  firmly  convinced 
of  the  efficacy  of  remedial  measures,  operating  on  the  various  functions 
through  the  surface  of  the  body,  that  branch  of  the  healing  art  included 
under  the  head  of  physical  therapy.  This  field  has  been  grossly  neglected 
for  various  reasons;  in  part  because  of  the  dominant  position  occupied 
by  drug  administration  in  the  minds  of  most  practitioners  and  very 
largely  because  of  the  time  and  effort  entailed  in  the  administration  of 
these  measures  and  the  acquisition  of  a  proper  technique. 

Water  is  a  very  valuable  instrument  in  combating  the  evil  results 
of  fever.  Baruch,  whose  persistent  advocacy  of  hydrotherapy  con- 
stitutes a  real  service  to  American  Medicine  and  has  not  received  half 
the  recognition  it  deserves,  points  out  that  the  value  of  water  lies  not 
so  much  in  its  physical  constitution  as  in  the  fact  that  it  is  an  admirable 
material  for  the  conveyance  of  heat  and  cold  and  that  strictly  speaking, 
thermotherapy  is  a  better  term  than  hydrotherapy  in  the  use  of  water. 
A  few  facts  should  be  borne  in  mind  in  considering  hydrotherapy. 

(1)  That  we  are  aiming  rather  at  the  toxemia  than  at  the  pyrexia. 

(2)  That  the  reaction  to  the  use  of  cold  water  is  the  sine  qua  non  of 
success.    (3)  That  friction  is  as  important  as  the  cold  in  many  of  the 
procedures. 

The  good  effects  of  the  cold  water  are  obtained  largely  through  the 
nervous  system.  The  impulses  pouring  in  through  the  countless  nerves 
upon  the  centres  result  in  &  slower,  stronger  heart  beat,  and  an  improved 
vasomotor  tone,  which  can  be  measured  in  terms  of  an  increased  blood 
pressure;  respiration  is  deepened,  cerebral  processes  improved,  and 
metabolism  enhanced. 

Without  detailing  the  various  procedures,  one  may  mention  as  the 
best  known,  the  Brand  bath  in  typhoid  fever  and  the  chest-compress 
in  pneumonia. 

Through  the  cold  air  and  cold  water  we  effect  much  the  same  results; 
the  time  of  year,  the  facilities  of  the  environment  and  the  reaction  of  the 
patients  determine  an  indication  for  one  or  the  other. 

Drugs.  Drug  administration,  like  the  other  measures,  is  aimed  not 
at  the  pyrexia  but  at  the  toxemia,  and  that  the  fever  is  influenced  is  due 
to  a  relief  of  the  toxemia  or  the  conditions  determined  by  it. 

Cathartics  occupy  an  important  position  among  the  drugs,  because 
they  prevent  a  stagnation  within  the  bowel  and  the  consequent  absorp- 
tion of  putrefactive  products. 

The  toxins  of  disease  impinge  upon  the  vital  nervous  centres  and  upon 
none  more  certainly  than  upon  the  vasomotor  centre.  Our  great  dread  in 


6  TREATMENT  OF  ACUTE  INFECTIOUS  DISEASES 

the  severe  intoxication,  such  as  typhoid  fever,  pneumonia,  diphtheria, 
scarlet  fever,  and  sepsis  is  a  circulatory  failure. 

Circulatory  Failure.  The  term  "circulatory"  is  used  advisedly, 
because  upon  this  we  can  all  agree,  but  when  we  try  to  fix  this  failure  in 
the  heart  or  in  the  vasomotor  apparatus  an  abundant  opportunity  for 
difference  of  opinion  arises. 

It  is  the  belief  of  some  clinicians  that  in  the  large  majority  of  cases 
it  is  the  vasomotor  mechanism  that  is  at  fault.  For  this  reason  drugs 
that  act  either  on  the  vasomotor  centre  or  on  the  vessels  seem  rational. 
Such  drugs  include  caffeine  and  I  think  it  should  be  given  in  sufficient 
dosage  and  so  administered  as  to  guarantee  its  arrival  at  the  goal  de- 
sired. 1  give  it  hi  the  form  of  one  of  the  soluble  double  salts,  that  of 
caffeine  and  sodium  benzoate  or  caffeine  and  sodium  salicylate,  in  doses 
of  five  grains  every  four  hours,  and  such  studies  as  I  have  made  upon  its 
effects  on  blood  pressure  show  that  its  effects  do  not  last  even  through- 
out this  period.  Next  to  caffeine,  I  use  a  10  per  cent,  or  20  per  cent, 
solution  of  camphor  in  olive  oil  or  sesame  oil  and  use  more  than  the  usual 
dose,  giving  at  least  five  grains  every  four  hours,  hypodermically,  often 
alternating  with  the  caffeine,  thus  giving  a  dose  every  two  hours.  Per- 
sonally I  have  less  faith  in  strychnine. 

That  we  can  exclude  the  heart  in  all  cases  I  do  not  believe  and  my 
experience  leads  me  to  believe  that  in  all  cases  of  circulatory  failure  the 
digitalis  group  is  more  reliable  than  the  vaso-motors.  I  use  digitalis 
in  doses  of  one-half  an  ounce  of  the  infusion  (15  c.c.)  three  or  four  times 
a  day  or  m.  xxx  (2  c.c.)  of  the  tincture  at  the  same  intervals,  and  ap- 
preciating that  it  will  not  become  operative  in  less  than  twenty- 
four  hours,  use  in  urgent  cases  as  an  initial  dose  one-half  milligram 
(gr.  1/120)  of  strophanthin  intramuscularly.  This  whole  question 
of  digitalis  medication  will  be  found  fully  elaborated  under  Pneumonia, 
Ghap.  IX. 

No  mention  has  been  made  so  far  of  the  antipyretics. 

In  the  early  stage  with  bounding  pulse,  aconite  may  afford  some  re- 
lief by  slowing  the  heart  through  the  vagus,  the  coal-tar  preparations 
may  be  used  with  relief  of  headache  and  other  pains,  but  here  again  the 
fall  of  temperature  is  incidental.  These  drugs  are  depressants  and 
should  never  be  used  where  the  circulation  is  impaired. 

Hyperpyrexia.  As  has  been  said,  fever  may  be  looked  upon  as  of 
purposeful  intent,  as  a  conservative  effort  on  the  part  of  the  organism 
to  accomplish  something  useful  to  itself.  If  this  be  so,  measures  directed 
at  the  fever  as  such  are  misdirected  if  not  pernicious,  and  it  will  be  noted 
that  the  treatment  of  fever  outlined  in  this  chapter  has  been  directed 
at  the  toxemia  accompanying  the  febrile  movement  rather  than  at  the 


FEBRILE  CONDITIONS  7 

latter;  but  as  was  said  in  the  beginning,  any  symptoms  primarily  useful 
may  in  the  end  become  harmful;  one  may  say  that  Nature  has  overshot 
the  mark.  Excessive  temperatures  fall  into  this  category  as  well  as 
prolonged  sustained  temperatures. 

Hyperpyrexia  threatens  cell  function  and  cell  integrity  as  increased 
protein  destruction  shows.  We  see  its  effects  best  hi  insolation  and  in 
certain  rheumatic  fevers.  In  these  cases  reduction  of  heat  is  life 
saving. 

We  have  no  better  method  than  the  direct  application  of  cold  in 
the  shape  of  cold  baths  or  ice  rubbed  upon  the  surface  of  the  body. 
The  patient  may  be  put  into  a  bath  of  90°  F.  and  the  water  cooled  down 
to  70°  F.  to  75°  F.  The  body  is  kept  immersed  until  the  body  tem- 
perature falls  below  the  danger  point,  but  it  is  wise  to  remove  the 
patient  when  it  falls  to  102°  F.,  as  collapse  may  ensue  on  efforts  to  reduce 
it  to  normal.  If  such  occurs,  stimulants  and  heat  are  indicated,  as  in 
collapse  from  any  other  cause. 

Antipyretics  of  the  coal-tar  group  are  not  comparable  in  efficiency 
or  safety  to  cold  water,  but  may  be  used  where  it  is  impossible  to  use 
the  latter. 

No  attempt  has  been  made  in  this  chapter  to  go  into  details;  only 
generalizations  have  been  laid  down  with  special  emphasis  given  to 
those  branches  of  therapy  commonly  neglected,  and  for  this  reason 
serum  therapy  or  vaccine  therapy,  which  are  specific  for  individual 
disease,  have  been  omitted,  but  will  be  considered  in  their  appropriate 
places. 

SUMMARY 

Symptoms  of  disease  are  primarily  the  expression  of  purposeful  in- 
tent on  the  part  of  organs  or  tissues  working  under  abnormal  con- 
ditions; are  conservative  efforts  and  should  be  respected  by  the 
therapist. 

Interference  with  symptoms  is  demanded  only  when,  having  sub- 
served their  purpose,  by  continuing  they  themselves  become  the 
source  of  exhaustion. 

Fever  is  a  term  ordinarily  used  to  cover  both  pyrexia  and  toxemia. 

The  treatment  of  fever,  then,  is  the  treatment  of  pyrexia  and  toxemia, 
and,  except  in  hyperpyrexia,  more  especially  to  toxemia. 

The  fundamental  principles  of  the  treatment  of  fever  are: 

1.  Rest. 

2.  Diet. 

3.  Fresh  Air. 

4.  Hydrotherapy. 

5.  Drugs. 

6.  Treatment  of  hyperpyrexia. 


8  TREATMENT  OF  ACUTE  INFECTIOUS  DISEASES 

Rest. 

Lessens   demand  on  muscular  and  mental   energy  and   conserves 

energy  for  purposes  of  repair  and  production  of  immune  bodies. 
Rest  in  practice  means : 

Rest  in  bed. 

Comfortable  bed. 

Well  ventilated  room. 

Good  nursing. 

Quiet. 

Relief  from  anxiety  and  concern. 

Sleep. 

Diet. 

Determined  by  the  realization  that  the  body  heat  and  the  perform- 
ance of  the  functions  of  the  muscles,  organs  and  tissues  demand  a 
source  of  energy  and  that  the  only  source  of  energy  is  food  or  the 
tissues  themselves. 

Energy  demands  at  rest  are  the  same  for  a  man  in  health  or  in  ill- 
ness: about  33  calories  per  kilo  or  2,300  calories  for  a  man  of  154 
pounds. 

Pyrexia  increases  demands  by  some  25  per  cent,  on  an  average,  i.  e., 
about  40  calories  per  kilo  or  2,800  to  3,000  for  an  adult. 

Toxemia  by  destruction  of  tissue  makes  even  greater  demands,  es- 
pecially in  prolonged  fevers,  and  amounts  of  food  equal  to  50-60^70 
or  even  more  calories  per  kilo  may  be  given ;  the  amount  depending 
on  the  patient's  ability  to  handle  it  and  on  the  gain  or  loss  of 
weight. 

Protein  needs  are  from  65  to  85  grams. 

The  more  prolonged  the  fever  the  more  urgent  the  observance  of 
food  requirements. 

Gastro-intestinal  functions,  secretion,  motility  and  assimilation  are 
affected  but  slightly  in  early  days  of  fever  or  in  profound  intoxi- 
cation. 

Rules  for  Feeding. 

Do  not  urge  food  in  early  hours  pr  days  of  fever  against  the  patient's 
anorexia,  but  when  it  disappears  appreciate  and  provide  for  the 
demand  for  food. 

Water  should  be  given  freely;  offered  to  the  patient,  not  awaiting 
his  request. 

Fresh  Air. 

Proper  ventilation  of  room — exclusion  of  visitors.     Open  air-|-on 

verandah  or  porch — observing  the  proper  technique  in  bed-making. 

(See  Pneumonia.) 
The  value  of  fresh  air  consists  mostly  in  its  stimulating  effects  on 

vital  centres,  reflexly,  through  its  effect  on  nerve  supply  to  the 

skin  of  face  and  mucous  membranes  of  air  passages. 
Essential  factors. 

Live  air,  moving  air. 


FEBRILE  CONDITIONS  9 

Hydrotherapy. 

Effect  same  as  that  of  air.     Water  is  a  conveyor  of  temperature. 

Cold  stimulates  vital  centres  reflexly  through  nerves  from  the  skin. 
Essentials  to  success:  water  must  be  cold;  friction  must  be  applied 

(it  is  the  alternating  cold  of  water  and  heat  of  hand  that  affords 

stimulation) . 
Patient  must  react. 

Drugs. 

Cathartics  to  prevent  or  relieve  stagnation  and  absorption  of  products 

of  putrefaction. 
Circulatory  stimulants. 
Vaso-motor  stimulants. 

Caffeine  in  form  of  soluble  salt  (double  salt  of  sodium  salicylate 
or  benzoate  and  caffeine).  Dose  gr.  iij-v  (0.20-0.30  Gm.)  every 
4,  3  or  2  hours. 

Camphor  in  10  per  cent,  to  20  per  cent,  solution  in  oil  (olive  or 
sesame  oil)  in  doses  equal  to  gr.  v,  (0.33  Gm.)  of  the  camphor 
every  4,  3  or  2  hours. 

Heart  stimulants.  For  immediate  action  strophanthin  into  muscle 
or  vein.  Dose,  1/2  milligram  (gr.  1/120).  Follow  up  with  or  in  less 
urgent  cases  begin  with  digitalis  infusion  5ss  (15  c.c.)  or  Tincture 
m.  xxx  (2  c.c.)  three  or  four  times  a  day  until  desired  effects  ensue 
or  signs  of  toxicity  of  any  kind  appear. 

Antipyretics — for  pain  and  discomfort  at  the  beginning,  in  the 
sthenic  stage  and  even  then  with  caution. 

Hyperpyrexia. 

Sudden  rise  of  temperature  to  106°  F.,  or  above,  or  prolonged  tem- 
peratures of  104°  F.-105°F. 

Cold. 

Best  as  baths.    Put  patient  in  at  90°  F.,  and  lower  temperature  to 
75°  F.  or  70°  F.  Take  out  when  temperature  of  body  falls  to  102.5°  F. 
Slush  baths  or  cold  sponges. 

Antipyretics  indicated  only  when  cold  water  is  inaccessible. 
Specific  treatment.    (See  individual  diseases.) 


CHAPTER  II 

DIET  IN  ACUTE  INFECTIOUS  DISEASES 

FEEDING  the  sick  is  both  a  science  and  an  art;  a  science  in  so  far  as 
it  takes  cognizance  of  the  great  laws  of  supply  and  demand  in  a  phys- 
iologic sense;  an  art  in  so  far  as  it  affects  the  application  of  these  laws 
to  the  individual. 

Energy.  All  matter  is  endowed  with  a  certain  amount  of  energy, 
which  manifests  itself  differently,  under  different  conditions.  Certain 
chemical  substances,  by  virtue  of  the  nature  of  the  elements  that  com- 
pose them  and  their  relationship  to  each  other,  that  is,  their  structure, 
have  the  power  to  produce  one  or  more  manifestations  of  energy.  They 
are  said,  then,  to  have  potential  energy. 

To  give  rise  to  the  manifestations  of  energy,  these  substances  must 
have  a  certain  degree  of  instability  or  lability;  that  is,  must  be  capable 
under  definite  conditions  of  undergoing  changes  in  structure,  disruptions, 
etc.,  all  of  which  give  rise  to  motion. 

The  substances  of  which  our  bodies  are  composed  and  food  on  which 
they  continue  to  exist  are  chemical  substances  of  a  highly  labile  char- 
acter, possessing  potential  energy,  which  in  the  process  of  catabolism  or 
breaking  down,  give  rise  to  motion,  which  conveyed  to  other  bodies  is 
manifested  as  work  or  is  expressed  as  heat,  to  neglect  the  lesser  forms  of 
energy  in  the  human  body,  such  as  the  electrical. 

Energy  is  as  indestructible  as  matter  itself.  It  can  be  transformed 
from  one  kind  to  another,  but  it  cannot  be  destroyed  nor  yet  created 
anew.  Different  manifestations  of  energy  have  definite  quantitative 
relationships  to  each  other,  as  Joule's  great  experiments  on  the  mechani- 
cal equivalent  of  heat  showed.  He  demonstrated  that  the  amount 
of  work  necessary  to  raise  1  Gm.  of  water  through  1  cm.  of  distance  was 
that  required  to  raise  42.55  Gm.  of  water  through  1°  C. 

I  have  said  that  the  conversion  of  the  potential  energy  of  the  body  or 
of  the  food  into  one  or  the  other  manifest  forms  of  energy  occurs  under 
definite  conditions.  The  definite  condition  in  the  body  which  gives 
character  to  its  manifest  energy  is  the  "vitality"  of  the  cell.  Moore 1 
calls  the  living  cell  an  "  energy  transformer."  He  says: 

"The  living  cell  is  not  a  peculiarly  constructed  membrane  obeying, 

1  Recent  Advances  in  Physiology  and  Biochemistry,  edited  by  Leonard  Hill, 
London,  1908. 


DIET  IN  ACUTE  INFECTIOUS  DISEASES  11 

even  where  it  seems  most  directly  not  to  obey,  the  physical  laws  of 
diffusion  and  osmosis;  but  is  an  energy  machine  or  transformer  by 
virtue  of  the  operation  of  which  a  form  of  energy  appears,  peculiar  in 
its  manifestations  and  phenomena  to  living  matter." 

The  kind  of  energy  that  this  transformer,  the  living  cell,  produces 
out  of  the  potential  energy  of  the  body  and  its  foodstuffs  is  almost 
entirely  thermokinetic,  that  of  work  and  heat,  and  as  we  can  express 
work  in  terms  of  heat,  we  may  reduce  the  total  activities  of  the  body 
to  terms  of  heat  and  express  them  as  equal  to  so  many  "calories"  or 
heat  units. 

The  "  calorie  "  is  a  term  used  to  express  that  amount  of  heat  which 
is  required  to  raise  1  c.c.  or  Gm.  of  water  through  1°  C.  More  properly, 
this  is  termed  a  "small  calorie/'  while  the  term  "large  calorie"  is  used 
for  the  amount  required  to  raise  1  kilogram  or  1  liter  of  water  through  1° 
C.,  i.  e.,  1  large  calorie  equals  1,000  small  calories.  Calories  referred  to 
in  this  work  are  large  calories. 

The  Caloric  Balance  of  the  Human  Body.  As  has  just  been 
said,  the  human  body  (the  cells  collectively)  is  an  energy  transformer; 
or  to  put  it  in  other  terms,  the  human  body  is  like  a  steam-engine,  con- 
suming fuel  for  the  purpose  of  doing  work  and  producing  heat;  but  the 
human  body  differs  from  a  steam-engine  in  this,  that,  lacking  fuel,  it 
will  consume  its  own  structuie  up  to  the  point  of  a  complete  collapse  of 
the  mechanism;  so  that,  to  maintain  the  integrity  of  the  transformer 
or  engine,  it  is  necessary  that  the  output  by  it  of  work  and  heat  shall  be 
exactly  met  by  the  fuel  afforded  it.  To  know  the  amount  of  food  the 
human  body  requires,  then,  we  must  know  the  amount  of  work  it  does 
and  the  amount  of  heat  it  elaborates  in  a  given  time. 

Now  Nature  has  given  to  the  individual  a  most  amazing  regulator 
to  adapt  the  supply  to  the  demand  on  which  no  device  of  man  can  ever 
improve;  that  is,  appetite.  When  one  thinks  that  day  after  day  and 
year  after  year,  the  body  retains  a  fixed  or  approximate  weight,  under 
the  most  varying  demands  of  work,  and  consequently  of  food,  under 
the  guidance  of  this  monitor,  one  is  lost  in  admiration;  but  as  there 
are  times,  in  the  stress  of  disease,  when  this  regulator  fails  or  by  the 
dictates  of  false  theories,  is  disregarded,  we  need  to  know  what  the 
demands  actually  are,  in  order  that  we  may  guarantee  that  they  may 
be  met. 

The  determination  of  the  caloric  output  in  man  has  been  made  pos- 
sible by  the  use  of  the  calorimeter  chamber  of  Pettenkofer  and  Voit, 
elaborated  and  perfected  by  Atwater  and  Benedict,  whose  work  in  this 
field  has  been  the  most  extensive  and  accurate  ever  done,  and  whose 
studies  of  food-values  have  been  accepted  by  the  government  as  stand- 


12  TREATMENT  OF  ACUTE  INFECTIOUS  DISEASES 

ards;  and  by  the  study  of  the  respiratory  quotient  determined  by  the 
simpler  apparatus  of  Zuntz. 

Work.  Still  another  way  'to  determine  the  caloric  needs  of  man 
is  to  determine  the  heat  values  of  the  foods  habitually  taken  by  normal 
individuals  in  different  callings.  These  analyses  of  the  average  intake 
and  output  agree  wonderfully  well.  For  men  doing  light  or  sedentary 
work,  clerks,  professional  men,  literary  men,  the  requirements  are 
between  2,400  and  2,600  calories;  for  those  whose  work  is  a  little  more 
arduous,  as  machinists,  shoemakers  and  the  like,  2,900  to  3,100  calories; 
for  those  doing  hard  muscular  work,  smiths,  masons,  etc.,  3,300  to  3,600 
calories,  while  those  doing  very  hard  work  run  up  much  higher,  the 
Maine  woodsmen  demanding  some  7,000  to  8,000  calories.  Football 
players  require  nearly  as  much. 

What  concerns  us  most  is  the  requirement  of  a  man  at  rest,  for  this 
is  the  condition  in  which  we  find  our  patients.  Rest,  too,  is  a  relative 
term,  and  as  used  here  means  that  degree  of  activity  which  obtains, 
when  a  patient  is  put  to  bed,  which  is  a  very  different  state  from  com- 
plete muscular  relaxation  or  that  prevailing  in  sleep.  At  rest  the  de- 
mands are  about  2,300  calories  or  33  calories  per  kilo  of  body  weight,  the 
average  man  weighing  70  kilos  or  about  150  pounds. 

A  fact  of  prime  importance  to  us  as  practitioners  is  that  educed  from 
the  work  of  Magnus-Levy,1  namely,  that  the  total  metabolism  is  the 
same  in  the  sick  man  as  in  health,  so  far  as  the  demands  of  muscular 
effort  and  heat  production  go;  but,  as  we  shall  see,  fever  and  toxemia 
increase  these  demands. 

Weight.  The  caloric  requirement  of  an  individual  depends  not  only 
on  the  amount  of  work  he  does,  but  also  on  the  size  or  bulk  of  his  body; 
and  while  we  have  spoken  of  the  requirements  of  a  man  at  rest  as  2,300 
calories,  it  is  meant  for  a  man  of  average  weight,  while  such  wide  varia- 
tions as  a  man  of  200  pounds  and  a  woman  of  100  pounds  are  common 
in  our  every-day  experience.  The  requirements  are  best  thought  of  in 
units  of  weight,  as  so  many  calories  per  kilo — for  a  man  at  rest  33  calories 
per  kilo. 

Here,  too,  certain  modifications  have  to  be  made,  as  in  the  excessively 
obese,  whose  fat  is  hardly  to  be  considered  in  the  same  light  as  the  more 
actively  metabolizing  tissues. 

Age.  The  figures  "33  calories  per  kilo"  obtain  only  for  adults.  In 
the  young  the  growth  has  to  be  taken  into  consideration,  which  in  certain 
periods  is  more  intensive  than  in  others;  e.  g.,  in  the  first  three  months 
of  life  the  demands  are  about  110  calories  per  kilo;  in  the  second  three 
months,  100;  in  the  last  half  of  the  first  year,  90;  at  the  end  of  the  second 

1  Quoted  from  Otto  Cohnheim:  Die  Physiologie  der  Verdauung  und  Erndhrung. 


DIET  IN  ACUTE  INFECTIOUS  DISEASES  13 

year,  75  to  80;  at  10  years,  60,  and  at  14  years,  52.  Indeed,  as  Cohnheim 
observes,  the  boy  of  10  requires  as  much  food  as  the  adult  who  does  not 
do  muscular  work,  while  the  youth  of  14  to  16  must  eat  3,000  calories, 
about  one-fourth  more  than  his  father  who  leads  an  intellectual  life. 

Body-surface.  In  consideration  of  the  fact  that  in  all  warm-blooded 
animals  the  production  of  heat  is  the  most  imperative  function  of  metab- 
olism, and  further  that  the  dissipation  of  it  is  largely  a  function  of  the 
skin,  there  stands  a  relationship  between  these  two,  closer  than  that 
between  metabolism  and  weight.  In  a  small  sphere  the  surface  is  greater, 
proportionally  to  the  contents,  than  in  a  large  one,  for  the  contents  in- 
crease as  the  cube  of  the  radii,  while  the  surfaces  increase  as  the  squares, 
so  that  in  the  smaller  bodies  the  radiation  is  relatively  greater  and  the 
heat  production  must  be  relatively  more  intense. 

So  it  is  that  we  find  in  the  infant  a  requirement  of  100  calories  against 
33  in  the  adult,  but  when  the  surfaces  are  compared,  it  is  found  that 
reckoned  in  calories  per  square  decimeter,  it  is  about  the  same  from  10 
weeks  to  adult  life,  13  to  14  calories  per  square  decimeter  (Pfaundler  and 
Schlossmann).  The  unit  of  weight  is,  however,  so  much  more  readily 
obtained  that  we  use  it  in  preference. 

Metabolism  experiments  carried  on  during  rest  have  shown  that 
whether  reckoned  on  the  one  unit  or  the  other  they  are  always  the 
same  for  all  individuals,  men  or  women,  sick  or  well.  It  must  be  re- 
membered, however,  that  the  conditions  of  the  experiment  produce 
more  nearly  real  rest  than  obtains  in  the  sick-room.  Differences  of 
temperament  determine  very  different  degrees  of  muscular  activity, 
while  certain  phases  of  an  acute  infection,  like  delirium,  become  a  matter 
of  serious  import  in  the  consideration  of  rest. 

As  has  been  said,  all  this  energy  manifested  as  work  and  heat  by 
the  body,  resides  potentially  in  and  is  derived  from  the  food.  The  food, 
then,  must  furnish  periodically  just  what  the  body  has  expended  in 
order  to  keep  the  latter  intact,  for  if  the  food  is  deficient, '  the  deficit 
will  be  made  up  out  of  the  body  itself,  as  long  as  it  can  stand  the  drain. 
Our  patient  at  rest,  then,  must  have  2,300  calories  of  food  a  day. 

Caloric  Value  of  Foodstuffs.  The  foodstuffs  are  divided  into  three 
classes,  fats,  carbohydrates,  and  proteins.  Strictly  speaking,  salts 
and  water  are  foodstuffs,  but  they  have  no  caloric  value. 

Rubner's  figures  for  the  caloric  value  of  foodstuffs  still  stand  to-day, 
such  slight  modifications  as  have  been  made  having  but  little  practical 
significance.  They  are  as  follows: 

1  Gm.  of  fat  furnishes  9.3  calories. 

1.  Gm.  of  carbohydrate  furnishes  4.1  calories. 

1  Gm.  of  protein  furnishes  4.1  calories. 


14  TREATMENT  OF  ACUTE  INFECTIOUS  DISEASES 

With  these  figures  and  a  table  of  the  average  composition  of  the 
common  foods,  like  those  of  Atwater,  published  by  the  U.  S.  Depart- 
ment of  Agriculture,  it  is  no  difficult  task  to  arrange  a  dietary.1 

The  first  step,  then,  in  arranging  a  diet  in  acute  infectious  diseases, 
is  to  provide,  as  a  minimum,  as  many  calories  as  are  demanded  by  the 
individual  when  at  rest  hi  health,  33  calories  per  kilo,  or  2,300  in  the 
average  man. 

A  diet  must  not  only  contain  sufficient  heat  units,  it  must  also  be 
properly  balanced  with  reference  to  the  three  foodstuffs,  and  of  these 
three,  the  most  important  is  protein. 

Protein  Needs.  Two  facts  of  great  importance  are  to  be  kept  in 
mind,  which  differentiate  protein  from  the  other  foodstuffs;  first,  in 
the  adult,  under  normal  circumstances,  the  daily  demand  for  protein 
is  fixed  and  does  not  vary  with  the  amount  of  work  done,  as  is  the  case 
with  the  other  two  foodstuffs;  and  second,  there  is  no  provision  for  a 
storage  of  an  excess  of  protein,  as  is  the  case  with  fats  and  carbohydrates. 
Therefore,  any  excess  must  be  catabolized  and  eliminated. 

This  daily  amount  of  protein  amounts  to  about  100  Gm.,  or  16  Gm. 
of  nitrogen.  Voit's  figures  are  118  Gm.  of  protein  as  ingested,  which, 
allowing  for  the  amount  found  in  the  stools,  gives  about  100  Gm.  net. 
The  analysis  of  dietaries  the  world  over  has  given  a  remarkable  una- 
nimity of  results,  which  have  confirmed  Voit's  figures. 

That  a  man  may  perform  hard  work  for  months  and  remain  in  ex- 
cellent condition  on  an  amount  of  protein  far  less  than  this,  one-half  and 
even  less,  has  been  demonstrated  by  Chittenden  in  the  most  elaborate 
and  extensive  set  of  experiments  ever  cariied  out  on  this  subject.  Phys- 
iologists, however,  though  they  must  accept  the  possibility  of  this  low 
protein  need  as  a  fact,  are  not  yet  inclined  to  argue  from  this  demon- 
stration that  such  an  intake  would  subserve  the  interests  of  the  organism 
in  the  long  run  to  the  best  advantage. 

Functions  of  Protein.  Protein  subserves  three  important  functions. 
First,  it  furnishes  substance,  building  material,  to  the  body.  This  is 
spoken  of  as  the  " storage"  of  nitrogen.  Second,  it  repairs  the  daily 
waste  of  the  body,  the  wear  and  tear  of  the  machine.  Third,  it  furnishes 
heat  in  its  combustion,  that  is,  is  a  fuel. 

It  is  only  in  early  life  that  the  first  of  these  functions,  storage,  is  of 
prime  importance.  At  that  time  it  is  one  of  the  most  imperative  of 
physiologic  functions.  The  continuance  of  growth,  when  weight  may 

1  An  excellent  table  of  food  values  expressed  in  units  of  100  calories  may  be 
obtained  from  the  J.  A.  M.  A.,  Chicago,  for  10  cents,  entitled  Extracts  from  Prac- 
tical Dietetics,  Irving  Fisher. 

Food  V allies:  Edwin  Locke — is  an  excellent  hand  book. 


DIET  IN  ACUTE  INFECTIOUS  DISEASES  15 

be  stationary  or  regressive,  is  a  familiar  phenomenon  to  the  pediatrist, 
expressive  of  the  fact  that  the  protein  is  seized  on  with  avidity  even 
when  the  fuel-value  of  the  food  is  insufficient  for  body  needs.  It  is  a 
curious  fact  that  the  actual  amount  of  protein  ingested  in  infancy  is 
about  the  same  month  after  month,  but  the  amount  devoted  to  storage 
decreases,  while  that  used  for  wear  and  tear  increases.  In  the  first  two 
weeks  over  75  per  cent,  is  stored;  at  two  months  40  per  cent.;  at  five 
months  23  per  cent.  When  an  individual  has  attained  his  or  her  growth, 
storage  ceases,  except  on  special  occasions;  these  are  during  pregnancy 
and  lactation,  in  the  establishment  of  hypertrophy  of  groups  of  muscles, 
as  in  the  training  of  an  athlete,  and  during  convalescence  from  wasting 
disease  or  after  a  long  fast. 

The  second  function,  repair  of  wear  and  tear,  is  the  important  one 
in  adult  life.  This  has  to  do  with  maintaining  the  integrity  of  the  ma- 
chine as  a  whole  and  has  nothing  to  do  with  the  amount  of  muscular 
work,  so  it  is  a  daily  constant,  regardless  of  the  amount  of  exertion  the 
body  has  been  put  to.  It  is  for  this  purpose  that  the  food  should  contain 
100  Gm.  of  protein  a  day  in  the  adult  diet. 

The  third  function  is  incidental.  Protein  does  furnish  heat,  but 
it  is  not  an  economical  source  of  supply.  In  the  infant  the  proper  amount 
of  protein  furnishes  about  7  per  cent,  of  the  calories;  in  the  adult  about 
14  per  cent. 

The  reason  that  protein  is  not  an  economical  fuel  lies  in  that  peculiar 
property  known  as  its  "  specific  dynamic  action."  When  food  is  ingested, 
the  physiologic  processes  sequential  to  it  produce  heat.  The  amount  of 
such  heat  induced  by  fat  and  sugar  is  slight  and  negligible,  but  not  so 
protein.  The  ingestion  of  this  substance  gives  rise  to  a  production  of 
heat  equal  to  a  trifle  more  than  30  per  cent  of  its  caloric  value. 

The  source  of  this  heat  is  a  matter  of  dispute,  but  it  would  seem 
to  be  due  to  the  work  of  the  glands  of  secretion  and  to  cell  activities 
with  which  we  are  less  acquainted.  Lusk  has  intimated  that  in  the 
case  of  protein  it  may  be  in  part  due  to  the  denitrogenization  of  the 
amidobodies.  This  heat  is  lost  to  the  body,  is  waste  heat,  under  the 
conditions  of  temperature  and  physical  regulation  of  heat  in  which 
man  lives.  He  cannot  utilize  this  heat  for  purposes  of  cell-life. 

This  loss  of  heat  by  the  specific  dynamic  action  of  protein  may  be 
expressed  in  this  way:  that  to  get  the  caloric  value  of  100  Gm.  of  protein 
one  must  ingest  140  Gm.  of  the  food.  It  is  this  increased  heat  that 
must  be  dissipated  that  has  led  naturally  to  a  limitation  of  meat  diet 
in  hot  weather  and  to  its  general  elimination  from  the  diet  of  fever. 

The  second  step,  then,  in  arranging  a  diet  in  the  acute  infectious 
diseases,  is  to  provide  enough  protein  to  replace  the  wear  and  tear, 


16  TREATMENT  OF  ACUTE  INFECTIOUS  DISEASES 

an  amount  which  hardly  differs  from  the  general  demand  in  health. 
It  may  be  placed  at  65  to  80  Gm. 

Fat  and  carbohydrates  differ  from  protein  in  two  very  striking  ways 
as  articles  of  diet;  first,  when  utilized  by  the  body  the  oxidation  is  com- 
plete and  they  are  eliminated  as  carbon  dioxide  or  water,  while  the 
nitrogenous  moiety  of  the  protein  is  not  completely  oxidized  and  entails 
work  on  the  part  of  the  kidney  to  eliminate  it,  which  the  other  food- 
stuffs do  not  require;  second,  an  excess  of  fat  and  sugar  beyond  imme- 
diate needs  is  stored  in  the  body  as  fat  and  does  not  demand  prompt 
elimination  like  the  excess  of  protein. 

The  proportions  of  the  three  foodstuffs  in  an  average  dietary  is  protein 
100  Gm.,  fat  50  Gm.,  and  carbohydrates  400  to  500  Gm.,  giving  in  the 
neighborhood  of  3,000  calories. 

Milk.  No  food  in  infectious  diseases  has  been  used  so  much  as  milk, 
and  frequently  to  the  exclusion  of  all  others. 

An  excellent  milk  will  show  on  analysis  about  4  per  cent,  of  fat,  4.5 
per  cent,  of  sugar,  and  3.5  per  cent,  of  protein,  or,  to  the  liter,  40  Gm.  of 
fat,  45  Gm.  of  sugar,  and  35  Gm.  of  protein.  Using  Rubner's  caloric 
values  as  given  above,  we  see  that  the  caloric  value  of  a  liter  of  milk  is 
700;  reduced  to  quarts,  there  are  about  640  calories  to  the  quart,  or  20 
to  the  ounce — a  convenient  figure  as  a  mnemonic. 

A  liter  contains  35  Gm.  of  protein  or  1  Gm.  to  the  ounce. 

It  will  be  seen  presently  that  a  low  estimate  of  the  caloric  needs  in 
fever  of  an  average  individual  is  3,000.  To  meet  this  one  would  have  to 
administer  over  a  gallon  of  milk,  which  would  contain  over  140  Gm.  of 
protein. 

These  figures  sufficiently  demonstrate  how  illy  adapted  an  exclusively 
milk  diet  is  to  meet  the  needs  of  an  individual  suffering  from  an  acute 
infection. 

Standard  Portions.  When  one  comes  to  study  the  tables  of  com- 
position of  foodstuffs,  it  is  plain  that  the  establishment  of  a  dietary  to 
respect  the  caloric  requirements  and  the  protein  needs  of  a  patient  is  a 
task  outside  the  time  and  patience  of  an  active  practitioner.  It  was  with 
an  appreciation  of  this  fact  that  Professor  Irving  Fisher,  of  Yale,  pub- 
lished his  tables  of  standard  portions. 

It  will  be  seen  from  the  table  representing  a  few  of  these  articles 
selected  how  remarkably  the  ordinary  servings  of  common  articles  of 
food,  or  at  least  multiples  or  simple  fractions  of  them,  amount  to  just 
100  calories. 

In  some  of  our  hospitals  the  nurses  are  now  instructed  to  bring  food 
to  the  patient  in  these  portions,  so  that  the  estimate  of  the  daily  intake 
can  be  easily  made  with  a  degree  of  accuracy  that,  though  not  adapted  to 


DIET  IN  ACUTE  INFECTIOUS  DISEASES  17 

research  work,  answers  all  practical  purposes,  and  because  the  daily 
exhibition  of  these  portions  is  an  education  to  both  the  medical  and 
nursing  staffs.  It  soon  becomes  an  easy  matter  to  think  of  the  ordinary 
articles  of  diet  in  terms  of  units  of  100  calories. 


TABLE  OF  FOOD-VALUES   IN  UNITS  OF 
100  CALORIES  i 

Protein 
in  Gm. 

Milk,  5  oz 5. 

Cream,  16  per  cent.  (2  oz.) 1.5 

Buttermilk,  one  and  one-half  glasses  (9.5  oz.) 8. 

Koumys,  one  glass  (7  oz.) 5. 

Whey,  two  glasses  (13  oz.) 3.5 

Eggs,  one  and  one-half 10 . 

Whites  of  eggs,  6 24. 

Yolks  of  eggs,  2 4.5 

Oatmeal,  one  and  one-half  serving  (5.5  oz.) 4.25 

Boiled  rice,  ordinary  cereal  dish  (3  oz.) 2.5 

Hominy,  large  serving  (4.2  oz.) 2.5 

White  bread,  home  made,  one  thick  slice  (1.25  oz.) 3.2 

One  small  Vienna  roll  (1.25  oz.) 3.2 

Butter,  one  pat  (0.5  oz.) 0.0 

Sugar,  three  teaspoonfuls,  one  and  one-half  lumps  (0.8  oz.) 0.0 

Macaroni,  cooked,  average  serving 3.0 

Spaghetti     "  "  3.4 

Tapioca       "  1.1 

Prunes,  edible  portion,  three  large 0.9 

Lemon  juice,  9  oz 0.0 

Oil,  one-third  ounce 0.0 

Codfish,  two  servings  (5  oz.) 23 . 

Halibut  steaks,  one  serving  (2.8  oz.) 15. 

Mackerel,  Spanish,  one  serving  (2  oz.) 12 . 2 

Shad,  one  serving  (2.1  oz.) 11.2 

Salmon,  small  serving  (1.5  oz.) 7.3 

Oysters,  12 12. 

Roast  beef,  ordinary  serving  (1.8  oz.) 10. 

Small  sirloin  steak  (1.4  oz.) 7.5 

Leg  of  lamb  or  mutton,  ordinary  serving  (1.8  oz.) 10. 

Lamb  chop,  one,  small  (1  oz.) 6. 

Bacon,  small  serving,  medium  fat  (0.5  oz.) 1.5 

Chicken,  broiler,  edible  portion,  large  serving  (3.2  oz.) 19. 

Turkey,  large  serving  (1.2  oz.) 7. 

Potato,  baked,  one,  good  size  (3  oz.) 3 . 75 

Potato,  sweet,  baked,  one-half  average  potato  (1.7  oz.) 1.5 

String  beans,  five  servings  (16.66  oz.) 3.75 

Spinach,  two  ordinary  servings  6.1  oz.) 3.7 

1  Adapted  from  Prof.  Fisher's  Tables.    Loc.  cit. 


18  TREATMENT  OF  ACUTE  INFECTIOUS  DISEASES 

Peas,  green,  one  serving  (3  oz.) 5.7 

American  or  Swiss  cheese,  1.5  cubic  inches  (0.75  oz.) 6. 

One  baked  apple,  3.3  ounces 0.5 

The  object  of  our  consideration  is  a  patient  suffering  from  an  acute 
infectious  disease:  So  far  I  have  discussed  only  the  food  requirements 
of  a  man  in  health  at  rest.  Such  a  discussion  is  relevant  to  this  subject, 
however,  because  the  requirements  of  the  patient  are  the  same  plus  a 
certain  additional  need  determined  by  the  infection  itself. 

There  are  four  factors  that  enter  into  the  problem  of  feeding  in  acute 
infectious  diseases  that  render  it  distinct.  They  are  (1)  gastro-intestinal 
disorders;  (2)  pyrexia;  (3)  toxemia;  (4)  starvation. 

Starvation  in  fever  has  been  a  tradition  in  medicine  that  has  lost  but 
little  authority  with  the  passage  of  time  and  finds  wide  acceptance  to- 
day. The  legitimacy  of  such  practice  I  wish  to  examine. 

Disturbance  of  Gastro-intestinal  Function.  It  cannot  be  denied 
that  the  gastro-intestinal  tract  is  not  indifferent  to  the  effects  of  the 
infection.  We  are  all  familiar  with  the  dry  mouth,  the  coated  tongue,  the 
anorexia  and  the  tympanites  of  many  of  the  patients. 

One  feels  little  inclined  to  urge  food  on  so  unwilling  a  receptacle  and 
this  feeling  has  plead  potently  with  many  practitioners  to  establish 
insufficient,  often  starvation  dietaries. 

Investigation  has  shown  that  the  salivary  secretion  is  lessened,  that 
the  output  of  hydrochloric  acid  is  diminished  and  the  motility  of  the 
distal  portion  of  the  intestine  is  impaired.  It  has  been  claimed  that  the 
motility  of  the  stomach,  too,  is  prejudiced  (von  Leyden  and  Klemperer), 
but  von  Noorden  maintains  that  that  has  not  been  the  case  in  the 
patients  he  has  studied. 

More  important  still,  assimilation  seems  to  be  good,  and  von  Leyden 
and  Klemperer1  found  that  in  different  patients  with  high  fever  89 
per  cent,  to  94  per  cent,  of  easily  digestible  fat  was  absorbed  and  91  per 
cent  of  protein.  Moreover,  they  found  no  carbohydrate  in  the  stools 
unless  excessive  amounts  had  been  ingested  or  diarrhea  prevailed. 

Taking  these  data  and  what  I  have  seen  of  liberal  feeding  in  febrile 
conditions,  I  am  convinced  that  the  ability  of  the  alimentary  tract  to 
perform  its  normal  functions  in  fevers  has  not  been  duly  appreciated  and 
the  withholding  of  food  on  the  supposition  that  this  organ  is  crippled  is 
unjustifiable. 

I  do  believe  that  in  the  incipiency  of  an  acute  infection  these  functions 
are  more  in  abeyance  than  later,  but  that  they  quickly  become  compe- 
tent. I  also  believe  that  the  state  of  the  mouth  and  digestion  is  due  in 
no  small  measure  to  an  insufficiency  of  water  and  is  greatly  aggravated, 

1  Von  Leyden  and  Klemperer:  Handbuch  d.  Erndhrungs-Therap,  1904,  ii,  332. 


DIET  IN  ACUTE  INFECTIOUS  DISEASES  19 

not  by  the  giving  of  food,  but  by  the  withholding  of  food,  which  en- 
tails a  destruction  of  body  tissue  and  sets  on  foot  abnormal  metabolic 
processes. 

Fever.  The  term  "fever"  as  ordinarily  used,  connotes  the  sum  of 
two  distinct  factors:  (1)  pyrexia,  and  (2)  toxemia.  These  will  be  dis- 
cussed separately,  and  when,  under  pyrexia  the  word  "fever"  is  used,  it 
is  to  be  taken  in  the  sense  of  an  elevated  temperature  alone,  i.  e.,  pyrexia. 

Pyrexia.  There  has  been  an  endless  controversy  from  remote  times 
as  to  the  significance  of  fever,  it  being  contended  on  the  one  hand  that 
it  was  a  deleterious  factor  in  the  disease,  on  the  other,  that  it  was  bene- 
ficial and  had  a  meaning  that  was  -to  be  respected;  purposeful,  the 
teleologist  would  say. 

This  is  not  the  place  to  discuss  at  length  fever  and  its  relation  to 
disease,  but  I  am  in  agreement  with  the  conclusions  of  careful  students 
of  the  subject  that  "  fever  is  a  specific  reaction  against  injurious  materials 
which  affect  the  tissues";  that  it  "is  in  its  essentials  a  protective  reac- 
tion," to  quote  from  the  excellent  article  on  fever  by  Dr.  W.  G.  Mac- 
Callum.1 

There  has  been  a  wealth  of  work  done  to  prove  this  statement,  which 
one  will  find  set  forth  in  detail  in  the  article  just  referred  to  and  in  a 
critical  review  of  the  subject  by  Hermann  Ludke.2 

Pyrexia  below  104°  F.  is  to  be  let  alone;  it  is  useful;  above  that  figure  it 
adds  an  element  of  harm  and  then  antipyretic  measures  are  indicated, 
but  not  till  then.  It  must  be  remembered  that  many  so-called  antipy- 
retic measures,  such  as  the  cold  baths,  are  directed  not  toward  the 
temperature,  but  to  the  circulatory  and  nervous  system,  and  are  of  the 
highest  value  when  these  systems  are  in  distress.  The  phenomena  of 
fever  lead  rapidly  to  the  assumption  that  there  is  a  great  increase  in  heat 
production  and  a  marked  retardation  of  heat  dissipation,  in  other  words, 
a  great  accumulation  of  heat  in  the  body.  This  is  only  partially  so.  The 
actual  increase  in  the  oxidative  processes  is  relatively  small,  while  the 
relation  between  heat  production  and  heat  dissipation  is  but  little  inter- 
fered with.  What  seems  actually  to  take  place  is  the  regulation  of  these 
processes  on  a  higher  level,  so  to  speak;  what  level,  that  is,  at  what  tem- 
perature, depending  on  the  effects  of  the  toxins  on  the  heat-regulating 
mechanism.  This  mechanism,  however,  under  such  conditions,  does  not 
display  the  same  degree  of  stability  as  in  the  normal  individual,  but  a 
lability  that  characterizes  the  temperature  curve  in  infections,  and, 
indeed,  gives  their  individual  stamp  to  them. 

1  MacCallum,  W.  G.:  Arch.  Int.  Med.,  1909,  ii,  569,  and  the  Harvey  Lectures, 
1908-1909. 
*  Ludke,  H. :  Ergebn.  d.  Inn.  Med.  u.  Kinderh,  iv,  493. 


20  TREATMENT  OF  ACUTE  INFECTIOUS  DISEASES 

I  have  said  that  the  increase  of  heat  production  in  fever  is  relatively 
small.  The  figures  vary;  sometimes  there  is  no  increase,  but  on  the 
average  it  amounts  to  about  25  per  cent.  This  might  seem  considerable 
did  we  not  pause  to  consider  that  in  strenuous  muscular  exercise  the 
increase  of  heat  amounts  to  several  hundred  per  cent. ;  for  example,  the 
8,000  calories  of  the  Maine  woodsman  to  the  2,300  at  rest. 

The  fact  that  such  great  increase  in  heat  in  the  normal  man  causes  no 
rise  of  temperature  shows  that  the  elevated  temperature  of  fever  requires 
an  additional  factor  to  that  of  heat  production;  that  It  is  the  result  of  the 
toxins  as  well  as  heat.  However,  as  our  patient  is  at  rest,  this  25  per  cent, 
increase  has  to  be  added  to  the  2,300  calories  allowed  him,  in  order  to 
make  good  his  daily  losses,  so  that  it  may  be  said  that  the  require- 
ment of  the  febrile  patient  is  40  calories  per  kilo  or  2,800  calories, 
near  enough  to  3,000  to  make  that  our  guide. 

One  other  effect  of  pyrexia  I  wish  to  mention;  that  is,  its  destructive 
action  on  protein.  As  Lusk  says,  "  Infectious  fevers  are  characterized  by 
a  toxic  destruction  of  body  protein";  but  there  are  three  factors  con- 
cerned in  the  loss  of  nitrogen  during  an  acute  infectious  process:  (1) 
pyrexia,  (2)  toxins,  (3)  starvation. 

The  study  of  non-toxic  fevers,  such  as  are  induced  by  exposure  to 
heat  or  by  puncture  of  certain  parts  of  the  brain,  show  that  the  pyrexia 
can  induce  protein  catabolism,  but  it  seems  to  demand  a  temperature  of 
102°  F.  or  over  to  bring  about  this  protein  loss,  and  experimentation  has 
shown  that  a  sufficient  feeding  can  control  this  loss. 

Toxemia.  It  was  recognized  that  apart  from  the  effect  of  pyrexia  and 
apart  from  starvation,  or  at  least  in  the  presence  of  food  sufficient  to 
meet  all  the  theoretical  considerations  we  have  so  far  set  forth,  there 
still  continued  to  be  a  considerable  loss  of  protein  in  the  acute  infectious 
diseases.  This  loss  came  to  be  accepted  as  inevitable  by  the  ablest 
investigators  in  the  field  and  was  attributed  to  the  effects  of  the  toxins 
and  was  called  the  "toxic  destruction"  of  protein.  Just  how  the  toxins 
brought  this  protein  loss  was  and  is  a  matter  of  conjecture.  It  has  been 
attributed  by  Krehl  to  actual  cell  destruction;  by  others  to  an  exciting 
effect  on  metabolism  by  the  toxins;  by  others  to  an  expression  of  the 
production  of  antibodies  and  other  protective  substances.  Certain  it  is 
that  it  is  dissociated  from  the  pyrexia,  as  such;  for  it  is  often  intense  when 
there  is  no  rise  of  temperature.  Taken  with  this  destruction  it  has  been 
suggested  that  a  weakened  power  of  regeneration  exaggerates  the  dif- 
ference between  catabolism  and  anabolism. 

Starvation.  This  does  not  belong  to  the  acute  infections  as  a  rule, 
except  as  it  is  inflicted  on  the  patient  by  an  insufficient  dietary.  Energy 
must  be  supplied  to  the  body  each  day  and  when  the  food  does  not  do  it, 


DIET  IN  ACUTE  INFECTIOUS  DISEASES  21 

the  body  substance  does  and  the  protein  is  called  on  to  do  its  share  at 
the  sacrifice  of  cell  integrity. 

At  the  present  moment  one  of  the  most  intensely  interesting  fields 
of  medical  research  is  that  devoted  to  metabolism,  the  building  up  and 
breaking  down,  anabolism  and  catabolism,  the  storage  of  energy  and 
its  dispersion;  what  one  writer  has  called  the  "most  fundamental  char- 
acteristic of  life,  energy-traffic."  The  intimate  processes  of  protoplasm 
yield  their  secrets  stubbornly,  but  we  know  what  they  have  to  work  on 
and  we  know  what  they  yield  back;  we  know  the  fuel  and  the  ash,  the 
intake  and  the  output,  and  from  the  knowledge  of  these  two,  we  deduce 
much  that  has  occurred  in  the  process  of  the  change. 

Nitrogen  is  the  basic  substance  on  which  the  body  structure  is  erected. 
It  is  ingested  with  the  food  and  it  is  expelled  in  the  urine,  the  stools  and 
in  lesser  measure  by  the  skin.  In  health  the  intake  and  output  balance 
each  other,  and  the  nitrogen  eliminated  is  divided  among  a  number  of 
combinations  which  maintain  a  pretty  constant  relationship  to  each 
other.  These  nitrogen  combinations  are  spoken  of  as  the  "  nitrogen 
partition." 

In  disease  the  balance  of  intake  and  output  is  disturbed  and  the 
relationship  of  the  combination  undergoes  a  change,  so  that  the  study 
of  the  nitrogen  partition  in  disease  is  a  tree  that  bears  much  fruit. 

I  have  said  that  the  nitrogen  elimination  is  divided  among  three 
organs,  the  kidneys,  the  intestine,  and  the  skin.  As  for  the  skin,  its 
output  is  negligible  except  when  made  to  functionate  in  an  unusual 
manner,  as  in  very  profuse  perspiration.  Under  such  circumstances 
it  has  been  known  to  yield  as  much  as  0.75  to  1  Gm.  of  nitrogen. 

The  stools,  however,  contain  an  appreciable  amount  of  nitrogen. 
Some  very  curious  ideas  prevail  even  among  physicians  about  the 
feces;  e.  g.,  that  they  represent  the  residue  of  the  food;  that  the  amount 
depends  entirely  on  the  amount  of  food  ingested;  that  if  there  be  no  food 
taken  there  should  be  no  feces.  The  stools  do  not  represent  the  residue 
of  food  so  long  as  the  food  is  free  from  indigestible  matter.  Stools  occur 
in  fasting  people  and  a  comparison  of  these  stools  with  those  ordinarily 
passed  shows  that  there  is  no  difference  in  their  composition  or  relation 
of  constituents,  no  matter  whether  there  be  much  or  little  food  taken, 
and  no  matter  whether  that  food  be  protein,  carbohydrate  or  fat.  The 
amount  increases  but  little  with  the  food  and  in  no  sense  in  proportion  to 
the  amount  ingested.  If  excesses  of  food  are  eaten,  a  minimum  residue 
may  appear  and,  of  course,  cellulose  or  other  indigestible  substance  is 
found. 

The  stools  are  made  up  of  the  residues  of  the  digestive  juices,  mucus, 
desquamated  epithelium,  bacteria,  the  products  of  bacterial  action,  salts 


22  TREATMENT  OF  ACUTE  INFECTIOUS  DISEASES 

and  water.  Of  the  salts,  it  must  be  remembered  that  the  intestine  is  the 
excretory  organ  for  iron  and  calcium  and  for  the  most  part  of  phosphorus 
and  magnesium. 

The  nitrogen  content  varies  from  1  to  2  Gm.,  but  on  the  whole  is  so 
constant  that  itlias  been  considered  as  furnishing  a  definite  per  cent,  of 
the  nitrogen  ingested  (15  per  cent.)  without  prejudice  to  the  accuracy  of 
the  metabolism  study. 

It  is  to  the  urine  that  we  turn,  however,  to  derive  important  in- 
formation; for  80  per  cent,  to  90  per  cent,  of  the  nitrogen  is  excreted  by 
the  kidney  as  urea,  uric  acid,  ammonia,  xanthin  bases,  creatinin,  and 
amidobodies. 

The  study  of  the  total  excretion  and  of  its  individual  constituents 
is  of  importance. 

Total  Nitrogen.  It  has  been  invariably  found  that  the  amount  of 
nitrogen  excreted  in  fever  far  exceeds  the  amount  ingested,  and  so  much 
the  more,  the  more  severe  the  process. 

It  is  common  enough  to  find  losses  of  8  Gm.,  12  Gm.,  16  Gm.,  and 
more  of  nitrogen  a  day;  that  is,  in  excess  of  the  intake;  and,  that,  too, 
when  on  a  diet  usually  considered  satisfactory.  This  latter  figure  is 
the  amount  of  nitrogen  demanded  in  Voit's  standard  dietary,  and 
if  it  were  interpreted  in  terms  of  muscle  tissue  would  mean  a  loss  of 
a  pound  of  such  tissue. 

Such  figures  will  be  found  repeatedly  in  the  tables  of  Shaffer  and 
Coleman's  studies  on  metabolism  in  typhoid  fever,1  and  those  of  Wolf 
and  Lambert 2  on  pneumonia. 

The  study  of  the  total  nitrogen  and  the  determination  of  the  "  nega- 
tive nitrogen  balance/'  as  it  is  called,  tells  us  that  there  has  been  loss  of 
substance  to  the  body,  but  it  does  not  tell  us  what  tissues  are  suffering 
this  loss,  nor  yet  whether  the  metabolic  processes  are  carried  out  in  a 
qualitatively  normal  manner.  Such  scant  information  as  we  have  along 
these  lines  is  derived  from  the  study  of  the  parts  that  go  to  make  up  the 
total;  that  is,  the  nitrogen  partition. 

It  is  the  small  portions  that  in  the  past  excited  but  little  interest 
that  are  now  yielding  us  the  most  information.  One  of  these  portions 
is  the  substance  creatinin.  When  Folin  3  published  his  classical  analyses 
of  thirty  normal  urines,  he  called  attention  to  the  fact  that  this  substance 
creatinin  remained  practically  constant,  no  matter  what  the  amount  of 

1  Shaffer  and  Coleman:  Arch.  Int.  Med.,  1909,  iv,  538. 

2  Wolf  and  Lambert:  Arch.  Int.  Med.,  1910,  v,  406. 

3  Folin:  Approximately  Complete  Analysis  of  Thirty  Normal  Urines;  Laws 
Governing  the  Chemical  Composition  of  Urine;  a  Theory  of  Protein  Metabolism, 
Am.  Jour.  PhysioL,  1905,  xiii,  45,  66,  117. 


DIET  IN  ACUTE  INFECTIOUS  DISEASES  23 

protein  ingested.  On  this  fact  he  elaborated  the  theory  that  this  sub- 
stance was  an  indicator  of  "tissue"  or  "endogenous"  metabolism  in 
contradistinction  to  "intermediate"  or  "exogenous"  metabolism,  of 
which  urea  is  the  chief  representative.  Another  representative  of  this 
"constant"  or  "endogenous"  metabolism  is  neutral  sulphur,1  and  to  a 
lesser  extent,  uric  acid  and  ethereal  sulphates. 

Folin  showed  that  this  substance  was  constant  in  the  individual, 
but  varied  in  different  individuals  according  to  body  weight.  He  spoke 
of  it  as  an  "index  to  the  amount  of  a  certain  kind  of  protein  metabolism 
occurring  daily  in  any  given  individual,"2  but  defined  that  kind  of 
"protein  metabolism"  no  further. 

Shaffer,3  however,  added  to  our  information  a  little  further,  by  show- 
ing that  not  only  was  the  output  of  creatinin  in  an  individual  constant 
from  day  to  day,  but  also  from  hour  to  hour,  amounting  from  7  to  11  mg. 
of  creatinin  nitrogen  for  every  kilogram  of  body  weight  per  twenty-four 
hours;  this  he  called  the  "creatinin  coefficient."  He,  moreover,  gave 
reason  to  believe  that  the  substance  was  an  index,  not  of  total  tissue 
metabolism,  as  Folin  thought,  but  of  one  tissue  metabolism,  that  of  the 
muscle,  as  its  output  seemed  to  show  a  parallelism  to  the  muscular 
efficiency  or  strength  of  the  individual.  It  has  nothing  to  do  with  the 
muscular  work,  but  rather  with  the  machine,  the  muscle  itself.  He 
suggests  that  it  is  an  index  of  muscle  tone.  If  one  may  use  an  analogy 
without  too  close  adherence  to  details,  one  might  consider  the  creatinin 
to  represent  the  friction,  the  daily  wear  of  the  muscle  machine,  not  at  all 
the  product  of  its  work. 

Here  was  an  important  clue  to  follow  up.  Any  substance  that  showed 
the  ravages  of  disease  in  so  important  a  tissue  as  muscle  was  worth 
looking  after.  Already  studies  on  the  substance  in  -pathologic  conditions 
had  assisted  to  suggest  the  above  view  of  its  significance  and  further 
work  confirmed  it. 

It  was  found  that  creatinin  was  diminished  in  conditions  of  muscular 
inefficiency,  such  as  amyotonia  congenita,  myasthenia  gravis,  muscular 
dystrophy,4  exophthalmic  goitre,  and  in  the  as  yet  undeveloped  muscles 
of  the  infant.5 

How  is  it  affected  by  acute  infectious  fevers? 

*The  importance  attributed  by  Folin  to  neutral  sulphur  as  an  expression 
of  "endogenous"  metabolism  has  more  lately  been  called  into  question. 

*  See  note  3  on  page  22. 

« Am.  Jour.  PhysioL,  1908,  xxiii,  1. 

4Spriggs:  The  Excretion  of  Creatinin  and  Uric  Acid  in  Some  Diseases  In- 
volving the  Muscles,  Quart.  Jour.  Med.,  1907-1908,  i,  63. 

'Amberg  and  Rowntree:  The  Excretion  of  Creatinin  in  the  Infant,  Bull. 
Johns  Hopkins  Hosp.,  February,  1910. 


24  TREATMENT  OF  ACUTE  INFECTIOUS  DISEASES 

There  is  a  pretty  constant  agreement  among  the  investigators  that 
it  is  increased  during  the  height  of  the  fever  and  is  most  marked  when 
the  nitrogen  loss  is  the  greatest,  but  there  is  no  numerical  relationship 
between  the  two.  During  convalescence  and  even  before,  there  is  a  dimi- 
nution in  the  excretion  which  may  be  attributed  to  muscular  weakness. 
It  must  be  interpreted  in  the  sense  that  the  febrile  condition  increases 
the  wear  and  tear  of  the  muscle  tissue.  This  increase  in  creatinin  was 
determined  for  typhoid  fever,1  for  pneumonias,  and  for  erysipelas. 

So  much  for  increased  wear  and  tear  of  the  protein  constituents 
of  the  body  during  the  acute  infectious  process;  but  is  there  anything 
that  bespeaks  by  its  presence  actual  destruction  of  a  definite  tissue? 
There  is  a  substance  in  the  tissue  closely  allied  to  creatinin,  which 
differs  from  it  only  by  the  presence  of  one  molecule  of  water  in  its  struc- 
ture (creatinin  is  a  dehydration  product  of  creatin),  which  does  not 
appear  normally  in  the  urine,  or  appears  only  in  traces.  This  is  called 
creatin. 

Creatin  is  to  be  found  in  the  urine  only  in  abnormal  conditions.  It  is 
found  in  wasting  diseases,  such  as  the  cachexia  of  carcinoma,  in  starva- 
tion, and  in  fevers.  It  is  derived  from  the  muscle  and  its  presence  in  the 
urine  means  destruction  of  the  substance  of  that  structure.  It  is  very 
striking  during  the  involution  of  the  uterus  after  childbirth.  It  was 
found  in  all  the  studies  on  fevers  referred  to,  and  sometimes  ran  over 
into  convalescence.  Its  disappearance  from  the  urine  is  looked  on 
as  a  good  omen,  and  what  interests  us  as  dietitians  is  that  when  made  to 
appear  in  starving  animals  it  has  disappeared  under  a  pure  carbohydrate 
diet. 

Besides  the  creatinin,  neutral  sulphur  and  uric  acid  are  both  increased 
and  may  be  looked  'on  as  further  expressions  of  increased  endogenous 
metabolism. 

So  far  we  have  considered  quantitative  changes  rather  than  quali- 
tative in  the  nitrogen  metabolism.  Qualitative  changes  might  be  taken 
as  evidence  of  metabolic  inefficiency. 

Evidence  of  this  is  to  be  looked  for  in  the  so-called  "  rest  nitrogen." 
This  "rest  nitrogen"  or  "undetermined  nitrogen"  is  that  nitrogen  which 
is  left  of  the  total  nitrogen  when  the  nitrogen  of  urea,  ammonia,  uric 
acid  and  creafcinin  have  been  subtracted.  If  the  "rest  nitrogen"  in- 
creases it  may  be  considered  as  being  at  the  expense  of  the  urea,  the  most 
important  nitrogenous  substance,  and  so  indicate  a  defective  deamida- 
tion.  The  amido-bodies  are,  indeed,  the  most  important  of  the  sub- 
stances included  in  the  "undetermined  nitrogen."  There  are,  besides 

1  Klercher:  "Ueber  Ausscheidung  von  Kreatin  and  Kreatinin  in  fieberhaften 
Krankheiten,"  Ztschr.  f.  klin.  Med.,  1909,  Ixviii,  22. 


DIET  IN  ACUTE  INFECTIOUS  DISEASES  25 

leucin  and  tyrosin,  indol,  skatol,  glycocoll,  proteic  acids  and  albumoses, 
as  well  as  xanthin  bases. 

Shaffer  and  Coleman  found  but  little  increase  in  the  "rest  nitrogen" 
in  typhoid  fever  and  the  same  was  true  of  pneumonia  investigated  by 
Wolf  and  Lambert  (there  was  absolute  increase,  but  not  in  dispro- 
portion to  total  nitrogen).  It  may  be  said,  then,  that  as  a  rule  the  urea- 
forming  function  is  but  little  impaired,  an  important  conclusion  in 
considering  the  ability  of  the  liver  to  handle  the  products  of  protein 
digestion. 

In  grave  cases,  such  as  were  observed  in  the  study  of  typhoid  metab- 
olism by  Ewing  and  Wolf,  the  "rest  nitrogen"  did  become  high  and 
the  urea  low. 

These  authors  looked  on  the  phenomenon  as  indicative  of  inefficiency 
of  the  liver  urea  formation,  recalling  the  high  "rest  nitrogen"  found  in 
acute  yellow  atrophy. 

Such  patients  probably  suffer  from  an  auto-intoxication  in  addition 
to  the  toxemia  of  the  disease. 

All  this  shows  that  in  acute  infectious  diseases  there  is  a  loss  to  the 
intrinsic  structure  of  the  body  and  that  while  such  loss  is  entirely  com- 
patible with  a  perfect  urea-forming  function — and,  indeed,  the  latter 
is  but  rarely  impaired  even  in  severe  cases — there  are  yet  a  certain 
number  of  grave  cases  in  which  the  liver  has  apparently  through  grave 
changes  in  its  structure  found  itself  incapable  of  dedamiation  and 
abnormal  metabolic  processes  are  in  evidence. 

With  this  knowledge  it  should  be  the  effort  of  the  therapeutist  to 
prevent  this  loss  and  perversion  of  function,  or  at  least  to  mitigate  them. 
Can  the  administration  of  food  accomplish  this,  and,  if  so,  how  shall 
it  be  ordered? 

It  would  seem  natural  to  conjecture  that  if  the  body  was  losing  10  Gm., 
15  Gm.,  or  20  Gm.,  of  nitrogen  a  day  over  the  intake,  such  a  loss  could  be 
made  good  or  prevented  by  increasing  the  intake  of  nitrogen  to  that 
amount.  The  truth  of  the  matter  is  that  neither  the  amount  of  the  loss 
nor  any  other  amount,  without  the  help  of  the  other  foodstuffs,  can  bring 
about  a  nitrogenous  equilibrium  in  man. 

The  work  of  Folin  and  Chittenden,  showing  the  small  amount  of 
nitrogen  which  is  really  needed  to  establish  an  equilibrium,  would 
lead  us  rather  to  use  the  smallest  amount  of  protein  necessary  and 
avoid  the  breaking  down  and  elimination  of  the  superfluous  nitro- 
gen radicles,  by  organs  burdened  with  disease,  and  increasing  the 
heat  to  the  fevered  organism  by  the  "specific  dynamic  action"  of  the 
protein. 

Shaffer  and  Coleman  were  able  to  establish  nitrogen  equilibrium 


26  TREATMENT  OF  ACUTE  INFECTIOUS  DISEASES 

in  typhoid  fever  on  from  10  Gm.  to  15  Gm.  of  nitrogen,  when  sufficient 
carbohydrate  was  used.  This  amount  will  be  seen  to  be  less  than  the 
Voit  standard  demands,  by  a  considerable  margin. 

Fat  and  carbohydrate  both  spare  protein;  not,  of  course,  replacing 
it,  for  they  are  both  nitrogen-free.  Fat  spares  the  combustion  of  protein 
to  furnish  heat;  and  weight  for  weight  furnishes,  as  has  been  shown,  over 
twice  as  many  calories  as  carbohydrates.  The  fat  of  the  body  is  utilized 
in  this  manner  as  a  protein-sparer.  Emaciation,  which  bespeaks  its 
disappearance,  makes  the  sufficiency  of  food  intake  all  the  more  impera- 
tive to  prevent  destruction  of  the  body  protein. 

Carbohydrate  is  a  very  much  more  efficient  sparer  of  body  protein 
than  fat.  Probably  much  of  the  demand  on  protein  in  the  underfed  body 
is  for  the  carbohydrate  moiety  of  its  structure.  Carbohydrate  is  im- 
perative to  life  and  must  be  had  at  any  cost.  This  the  ingested  carbo- 
hydrate furnishes,  so  that  it  both  furnishes  heat  as  does  the  fat,  and  also 
subserves  other  functions  which  the  fat  cannot  do. 

Nitrogen  equilibrium  has  been  struck  and  the  subjects  kept  at  from 
5  Gm.  to  8  Gm.  days  and  weeks  with  comfort  and  apparent  health, 
when  enough  carbohydrate  and  fat  are  taken. 

The  above  statements  hold  for  the  protein-sparers  in  health.  In 
acute  infections  their  influence  is  not  so  marked  quantitatively.  Von 
Noorden  says  that  in  experimentally  induced  pyrexia  the  protein  metab- 
olism is  not  limited  to  the  same  amount  in  the  presence  of  carbohy- 
drates as  when  the  temperature  is  normal. 

It  would  seem  possible,  then,  by  covering  the  caloric  needs  of  a  resting 
patient  and  adding  the  25  per  cent,  increase  induced  by  pyrexia,  to  keep 
a  patient  in  nitrogenous  equilibrium.  In  an  average  man  this  would 
mean,  as  before  stated,  about  3,000  calories.  In  practice,  however,  it  is 
not  true;  and  it  was  for  this  very  reason  that  protein  loss  still  continued 
in  acute  infections,  when  the  theoretical  food-needs  had  been  liberally 
met,  that  investigators  in  general  were  convinced  that  this  loss  was  due  to 
destruction  of  the  cell  substance  by  the  poisons  of  the  disease — "toxic 
destruction" — and  that  no  diet  could  prevent  it. 

That  this  loss  can  be  prevented  and  that  such  a  fact  impairs  the 
theory  of  "  toxic  destruction,"  the  elaborate  observations  of  Shaffer 
and  Coleman  show.  They  prevented  nitrogenous  loss  and  the  elimina- 
tion of  creatin  and  increase  of  neutral  sulphur,  which  are  taken  as  the 
expression  of  cell  destruction.  They  found  that  from  sixty  to  ninety 
calories  per  kilo  were  needed  to  effect  such  a  result  in  typhoid  fever.  Of 
this  amount  forty  to  fifty  or  even  more  calories  per  kilo  must  be  furnished 
by  carbohydrates.  They  point  out  that  a  loss  of  10  Gm.,  of  nitrogen  or 
62.50  Gm.,  of  protein  can  furnish  but  250  calories,  and  have  no  explana- 


DIET  IN  ACUTE  INFECTIOUS  DISEASES  27 

tion  to  offer  for  the  fact  that  2,000  calories  of  carbohydrate  are  needed 
to  prevent  this  loss. 

It  has  been  proved,  then,  that  in  some  men  suffering  from  severe 
acute  infectious  disease,  the  usual  protein  loss  can  be  stayed  by  the 
administration  of  a  large  quantity  of  foods. 

Vitamines.  One  of  the  most  recent  contributions  to  the  subject  of 
dietetics  is  the  discovery  of  certain  food  elements  absolutely  necessary 
to  nutrition,  which  are  present  in  minute  quantities  and  have  been 
termed  vitamines.  There  are  two  groups  of  vitamines  the  chemical 
nature  of  which  has  not  been  identified,  but  which  take  their  name  from 
the  mode  of  extraction.  They  are  called  "fat  soluble  A"  and  "water 
soluble  B."  Their  absence  from  foodstuffs  produces  nutritional  dis- 
orders of  which  the  best  known  and  most  carefully  studied  is  Beri  Beri 
and  perhaps  the  most  common  marasmus.  Bread  made  of  bolted  flour 
and  cow's  milk  which  constitute  so  considerable  a  portion  of  the 
dietary  of  invalidism,  are  deficient  in  vitamines.  Whole  wheat  flour, 
unpolished  rice,  barley,  yellow  meal,  white  potatoes,  peas,  beans  and 
other  legumes,  fruit,  eggs,  all  contain  vitamines  and  should  enter  in 
some  proportion  into  the  dietary.  It  is  understood  that  vegetables 
and  fruits  must  be  fresh  as  the  canned  products  are  found  deficient 
in  vitamines. 

In  this  chapter  I  have  dealt  only  with  those  laws  that  constitute  the 
science  of  dietetics.  The  application  of  these  laws  to  the  individual;  the 
appreciation  of  those  factors  that  make  every  individual  deviate  from 
the  type;  the  adjustment  of  theory  to  conditions,  constitute  the  art  of 
dietetics. 

SUMMARY 

The  body  is  a  mechanism  for  the  conversion  of  one  kind  of  energy 

(potential)  into  other  forms  of  energy,  for  the  most  part  heat  and 

work  (thermo-kinetic). 

Total  energy  may  be  expressed  in  terms  of  heat. 
The  heat  unit  is  called  the  calorie. 
Small  calorie  expresses  that  amount  of  heat  required  to  raise  1  c.c.  or 

gram  of  water  through  1°  C. 
Large  calorie  equals  1,000  small  calories. 
The  calories  referred  to  in  the  text  are  large  calories. 
The  calorie  requirements  of  a  man  depend  on  his  size,  his  age  and 

his  activities;  hence  his  calling  or  occupation. 
The  requirements  at  rest  (in  ordinary  acceptance  of  the  term)  in 

bed,  are  33  calories  per  kilo  of  body  weight  or  for  man  of  70  kilos 

(154  pounds)  2,300  calories. 
The  requirements  are  the  same  for  man  at  rest,  whether  he  is  sick  or 

well. 


28  TREATMENT  OF  ACUTE  INFECTIOUS  DISEASES 

Calorie  requirements  per  kilo  are  much  higher  in  the  young. 
Calorie  requirements  per  unit  of  body  surface  are  much  the  same  at 
all  ages. 

ARRANGEMENT  OF  DIET  IN  ACUTE  INFECTIOUS  DISEASES 

1.  Provide  as  a  minimum  the  calories  demanded  by  the  individual 
at  rest;  i.  e.,  for  adult  man  2,300  calories. 

2.  Provide  enough  protein  to  replace  wear  and  tear;  i.  e.,  for  an 
adult  65  to  80  grams. 

3.  Add  to  calories  demanded  at  rest  the  amount  required  by  extra 
heat  production  of  fever;  on  an  average  25  per  cent,  rest  require- 
ment; i.  e.,  for  adult,  total  of  40  calories  per  kilo  or  2,800  to  3,000 
calories. 

4.  Add  calories,  especially  in  form  of  carbohydrates,  to  shelter  pro- 
teid  loss.     May  require  60  or  more  calories  per  kilo.     Amount 
determined  by  loss  or  gain  in  weight,  i.  e.,  4,000  or  more  in  total. 

Protein  Needs. 

Voit's  standard  118  grams. 

Actual  need  shown  by  Cbittenden  to  be  less  by  nearly  one-half. 

Functions  of  Protein. 

1.  Storage  of  nitrogen,  in  growing  child,  in  pregnancy,  in  lacta- 
tion, in  hypertrophy  of  muscles  from  exercise,  and  in  convales- 
cence from  disease. 

2.  Repair — wear  and  tear  of  day. 

3.  Fuel — protein  is  not  an  economic  fuel  because  of  high  "  specific 
dynamic  action." 

Vitamines  necessary  for  an  accurately  balanced  dietary. 

Milk. 

Analysis.    Fat,  4  per  cent.;  sugar,  4.5  per  cent.;  protein,  3.5  per  cent. 
Caloric  value,  700  to  1  liter. 
620  to  1  quart. 
20  to  1  ounce. 

Protein  content,  35  grams  to  1  liter. 
32  grams  to  1  quart. 
1  gram  to  1  ounce. 

Not  well  balanced  for  sole  article  of  diet. 

Disturbance   of   gastro-intestinal   function   slight   at   beginning   of 
fever. 

Fever. 

Ordinary  use  of  term  connotes  effects  of  1.  pyrexia,  2.  Toxemia. 

Pyrexia. 

Increases  caloric  demand  even  up  to  50  per  cent.    Average,  25  per 

cent. 
Toxemia  accelerates  destruction  of  body  protein;  demands   high 

calorie  intake  to  prevent  it. 


DIET  IN  ACUTE  INFECTIOUS  DISEASES  29 

Starvation. 

Inflicted  on  patient  by  insufficient  diet. 

Feeding.    Early  in  fever  anorexia  is  a  conservative  symptom  and  to 

be  respected. 
After  first  few  days  gastro-intestinal  functions  are  competent  and 

food  should  be  administered  to  meet  needs. 
Water  needs  are  high  in  fever.    It  should  be  given  freely. 


CHAPTER  III 

ACUTE  RHEUMATIC  FEVER 

Theories  of  Rheumatism.  It  is  not  my  purpose  to  discuss  the  nu- 
merous theories  advanced  to  account  for  the  phenomena  of  acute  rheu- 
matic fever.  I  will  merely  state  that  it  is  the  consensus  of  opinion  at  the 
present  time  that  the  disease  is  an  acute  infection.  Numerous  observers 
have  claimed  to  have  isolated  the  specific  organism,  among  the  most 
insistent  of  whom  are  Poynton  and  Payne. 

Etiology.  The  classification  of  this  "specific"  organism  has  not  as 
yet  been  fairly  settled;  indeed,  the  identity  of  the  "specific"  organisms  is 
much  in  question.  Some  believe,  moreover,  that  different  organisms  can 
produce  the  same  clinical  complex  called  Rheumatic  Fever  and  one 
observer,  Rosenow,  maintains  the  transmutation  of  members  of  the 
streptococcus  group  into  several  forms,  each  inducing  some  differences  in 
the  clinical  picture.  This  will  be  touched  upon  again  when  discussing 
vaccine  therapy.  To  Poynton's  view  has  been  lent  the  weight  of  the 
authority  of  Osier's  new  Modern  Medicine,  to  the  pages  of  which  he 
contributes  the  article  on  rheumatism,  and  in  which  the  various  views  of 
the  etiology  of  this  disorder  are  set  forth  in  some  detail. 

Age.  About  one-half  of  all  cases  of  rheumatism  occur  between  the 
ages  of  fifteen  and  twenty-five  years;  about  one-quarter  in  the  next  de- 
cade, that  is,  between  twenty-five  and  thirty-five  years.  My  own 
impression,  based  on  considerable  contact  with  children,  is  that  the 
figures  set  for  childhood  are  too  low,  as  the  disease  is  peculiarly  insidious 
at  this  age,  and  deviates  strikingly  from  the  type  as  established  in  the 
adult.  The  serious  complications  are  quite  as  common,  even  more 
common  than  in  the  adult.  Of  the  cases  occurring  in  childhood,  70  per 
cent,  fall  between  the  ages  of  ten  and  fifteen  years. 

I  cannot  refrain  from  intercalating  a  bit  of  pediatric  wisdom  at  this 
juncture:  (1)  Beware  of  a  diagnosis  of  rheumatism  in  infancy.  It  is  so 
rare  that,  when  authentic,  it  warrants  rushing  into  print,  which  is  say- 
ing a  good  deal.  The  so-called  rheumatic  joints  of  infancy  are  almost 
certainly  pyogenic,  scorbutic,  or  syphilitic.  (2)  Scan  every  child's 
heart  with  care,  and  seek  constantly  in  the  histories  for  tonsillitis,  stiff 
neck,  and  especially  "growing  pains."  How  many  children's  lives  have 
been  sacrificed  to  that  unfortunate  term  no  man  can  estimate. 

How  readily  rheumatism  in  children  may  be  overlooked  is  shown 


ACUTE  RHEUMATIC  FEVER  31 

by  Langmead  who,  examining  2,556  English  school  children,  found  that 
5.2  per  cent,  of  them  showed  evidences  of  rheumatism  and  4.49  per  cent, 
of  them  in  terms  of  heart  disease. 

While  this  percentage  is  larger  than  one  would,  in  all  probability,  find 
among  our  children,  still  among  1,000  children  coming  to  my  clinic  at 
Bellevue  Hospital  just  1  per  cent,  showed  valvular  heart  disease,  for  the 
most  part  unrecognized. 

Symptomatology.  That  the  disease  is  rather  abrupt  in  its  onset, 
accompanied  by  fever,  that  sore  throat  is  not  uncommon,  that  drenching 
acid  sweats  may  occur,  and  that  the  inflamed  joints  are  the  pathogno- 
monic  sign,  is  all  well  known,  and  is  reiterated  here  merely  to  emphasize 
the  points  of  attacks  in  the  application  of  therapy.  The  complications 
are  the  important  events  in  the  course  of  rheumatism,  and  will  be  con- 
sidered after  rules  have  been  laid  down  for  the  simple,  uncomplicated 
case. 

Therapy.  A  sick  man  invites  medical  attention  for  two  reasons: 
First,  he  wants  to  be  cured  of  his  disease;  and  second,  he  wants  to  bemade 
more  comfortable  during  his  illness.  To  treat  a  patient  intelligently,  it 
goes  without  saying  that  a  diagnosis  is  imperative,  but  the  intellectual 
satisfaction  derived  from  establishing  a  diagnosis  must  not  lead  to  a 
satiety  that  eschews  further  effort  directed  toward  relief  of  the  condition. 
Such  a  comment  is  justified  by  fact.  Still  another  function  to  be  sub- 
served by  the  physician  is  the  instruction  of  the  patient  how  to  avoid  a 
repetition  of  the  attack.  There  are  certain  measures  that  may  be  di- 
rected toward  any  acute  illness,  others  that  are  aimed  at  the  particular 
disease  in  question.  This  order  will  be  preserved. 

Rest.  In  the  rheumatism  of  adults  the  painful  condition  of  the  joints 
impels  rest,  willy-nilly,  but  this  by  no  means  obtains  in  children.  Pain, 
which  he  who  suffers  it  looks  upon  as  an  unmixed  evil,  is  more  often  a 
boon  than  a  bane.  If  one  will  get  in  the  habit  of  analyzing  the  symptoms 
of  disease  in  terms  of  efforts  on  the  part  of  Nature  to  accomplish  a  useful 
purpose,  or  as  expressions  of  compensations,  he  will  be  amazed  to  see 
how  many  hints  these  symptoms  give  that  they  are  to  be  utilized  as  allies, 
not  combated  as  enemies. 

In  rheumatism  there  are  three  emphatic  reasons  why  rest  should 
be  insisted  on:  (1)  Because  the  body  cells  are  busied  in  combating  an 
intoxication,  for  which  then-  energy  should  be  conserved  as  much  as 
possible;  (2)  because  certain  tissues  are  undergoing  the  alteration  inci- 
dent upon  inflammation,  and  are  struggling  to  accomplish  repair;  and 
(3)  because  the  spectre  of  cardiac  involvement  is  never  absent  from  the 
disease,  and  we  fear  that  every  increment  of  activity  on  the  part  of  that 
organ  may  heighten  the  possibility  of  the  dreaded  disaster. 


32  TREATMENT  OF  ACUTE  INFECTIOUS  DISEASES 

To  illustrate  the  significance  of  rest,  I  will  cite  the  following  figures: 
One  knows,  as  a  fundamental  physiological  fact,  that  the  energy  and 
heat  of  the  body  are  derived  from  the  combustion  of  the  foodstuffs,  and 
that  the  carbon  of  these  foodstuffs  is  in  large  measure  eliminated  from 
the  body  through  the  lungs  as  carbon  dioxide;  so  -we  can  collect  and 
estimate  the  amount  of  carbon  dioxide  eliminated  in  a  unit  of  time, 
and  look  upon  the  results  as  expressions  of  the  activity  of  the  body 
cells  during  that  period.  This  has  been  done  repeatedly,  and  the  same 
individual  who  during  sleep  eliminates  22  grams  of  carbon  dioxide  per 
hour  will,  when  awake  and  exercising  the  greatest  amount  of  muscular 
relaxation  possible,  eliminate  31  grams,  and  under  conditions  ordinarily 
considered  those  of  rest,  38  grams.  In  this  light,  rest  assumes  a  meaning, 
and  the  importance  of  restlessness  and  loss  of  sleep  in  disease  is  enhanced 
in  dignity. 

The  two  important  factors  to  be  considered  in  estimating  the  amount 
of  work  done  by  the  heart  are  the  amount  of  blood  expelled  and  the 
pressure,  that  is,  resistance,  to  be  overcome.  The  lessened  heart  rate  in 
recumbency  and  the  diminution,  even  though  moderate,  of  blood  pres- 
sure in  this  attitude  will  suffice  to  emphasize  the  importance  of  rest 
to  this  organ. 

Rest  should  be  in  bed.  One  might  suppose  this  injunction  to  be  super- 
fluous, and  yet  it  is  every  one's  experience  not  infrequently  to  find 
himself  in  the  presence  of  contentious  individuals  who  demand  many 
reasons,  when  it  might  be  supposed  common  sense  would  dictate;  and 
one  might  as  well  write  in  golden  letters  on  the  tablets  of  his  memory  that 
he  is  to  treat  individuals,  whose  very  individuality  depends  on  differ- 
ences, not  machines  nor  yet  diseases. 

Bed.  The  bed  should  be  of  a  height  and  width  most  convenient 
for  handling  the  patient,  who  is  in  many  instances  helpless,  and  to 
whom  the  most  gentle  handling  may  constitute  torture.  A  half,  or  at 
the  most  a  three-quarter  bed,  with  a  woven  wire  spring,  sufficiently 
stiff  to  prevent  sagging,  should  be  chosen.  The  standard  hospital  bed 
is  an  admirable  example.  The  mattress  should  be  soft,  but  resilient  and 
firm.  A  good  hair  mattress  is  preferable.  If  the  patient  perspires  freely, 
the  bed  should  be  made  with  thin  blankets  instead  of  sheets.  The 
patient  should  wear  a  thin  flannel  nightgown,  opened  all  the  way  down 
the  front  and  slit  along  the  sleeves,  so  that  the  joints  may  be  exposed  for 
inspection  or  treatment  with  the  least  disturbance,  and  it  is  well  to 
throw  a  thin  flannel  cape  about  the  shoulders.  The  nurse  should  be  in- 
structed to  put  the  clothes  on  this  bed  with  a  view  to  the  comfort  of  the 
patient,  rather  than  to  preserve  the  symmetrical  and  esthetic  effect  so 
often  insisted  on  in  the  hospital  ward,  regardless  of  the  comfort  of  the 


ACUTE  RHEUMATIC  FEVER  33 

patient.  Often  the  lightest  touch  of  the  clothes  is  agonizing  to  the 
patient,  and  hoops,  cradles,  or  other  contrivances  to  take  the  weight  of 
the  clothes  off  the  patient  must  be  utilized. 

An  excellent  bed  is  one  of  which  the  so-called  Gatch-bed  is  a  type. 
It  consists  of  an  extra  frame  on  which  the  mattress  lies,  broken  at  two 
places  so  that  it  can  be  raised  and  maintained  by  a  ratchet.  The  break  at 
the  upper  end  of  the  bed  affords  an  excellent  bed  rest  that  can  be  readily 
maintained  at  any  angle,  while  a  second  break  at  about  the  bend  of  the 
knee  allows  the  raising  of  the  bed  at  this  point  which  gives  the  support 
and  prevents  the  body  from  sliding  down  and  is  a  grateful  change  in  the 
position  of  the  extremities.  Such  a  bed  is  particularly  valuable  in  cardiac 
cases  with  orthopnea. 

Room.  The  best  available  room  should  be  chosen,  with  a  view  to  an 
abundance  of  light  and  air,  with  a  southern  exposure  in  the  winter,  and 
away  from  the  prevailing  winds  at  all  times.  The  bed  should  be  so  placed 
that  the  draughts  may  be  avoided  but  the  air  not  shunned.  The  thera- 
peutics of  light  is  not  duly  appreciated.  The  minds  and  bodies  of  many 
of  us  are  as  responsive  to  its  influence  as  a  photographic  plate.  Air 
should  be  admitted  to  the  room  freely.  There  can  be  no  superfluity  of 
fresh  air.  In  summer  the  windows  should  be  kept  wide  open.  In  the 
winter  the  room  should  be  frequently  aired  and  kept  at  65°  to  70°  F. 
Personally,  I  do  not  hesitate  to  admit  the  cold  clear  air  of  a  winter's  day 
to  the  sick  room,  observing  proper  precautions  with  reference  to  the 
patient's  coverings. 

Diet.  If  there  is  any  one  field  within  the  province  of  medicine  that 
promises  richer  yield  than  another  for  the  labor  expended  on  it,  it  is  that 
of  dietetics.  As  yet  it  is  almost  virgin,  and  still  such  results  as  have 
been  obtained  are  of  the  highest  significance.  It  has  been  well  suggested 
that  if  the  physician  would  give  the  same  amount  of  time,  work,  and  care 
to  the  prescription  of  foods  that  he  does  to  drugs,  enormous  benefit 
would  accrue  to  bis  patients. 

In  the  first  place,  a  sick  man  needs  food,  and  he  needs  more  food 
than  is  ordinarily  given  him.  Of  course,  one  grants  that  there  are 
certain  conditions  that  make  the  administration  of  sufficient  food  diffi- 
cult or  impossible,  but  that  does  not  obtain  in  the  majority  of  instances.1 
As  I  have  said,  the  energy  and  heat  of  the  body  are  derived  from  the 
combustion  of  its  foodstuffs,  and  as  energy  can  be  conveited  into  heat, 
the  value  of  the  foodstuffs  can  be  expressed  in  heat  units.  Moreover, 
the  amount  of  energy  and  heat  the  body  gives  off  in  a  day  can  be  meas- 
ured in  terms  of  heat  units;  so  that  we  can  determine  just  how  much  food 
an  individual  of  a  given  weight,  under  varying  conditions  of  activity, 
1  See  Chapter  II,  Diet  in  Acute  Infectious  Diseases. 


34  TREATMENT  OF  ACUTE  INFECTIOUS  DISEASES 

needs.  The  term  adopted  to  express  a  heat  unit  is  the  "  calorie."  The 
amount  of  heat  that  1  calorie  represents  is  that  required  to  raise  1  kilo- 
gram of  water  from  0°  to  1°  C.  This  calorie  is  sometimes  spoken  of  as  the 
" large  calorie."  The  "small  calorie"  is  the  amount  of  heat  needed  to 
raise  1  gram  of  water  through  1°  C.  of  heat;  therefore,  1  "  large  calorie" 
equals  1,000  "small  calories."  Unless  qualified,  the  term  "calorie" 
means  a  "large  calorie." 

Now,  under  what  is  ordinarily  known  as  rest,  a  man  gives  off  heat  in 
twenty-four  hours  equivalent  to  about  33  calories  per  kilo  of  body 
weight;  that  is,  a  man  weighing  70  kilos,  or  154  pounds,  will  give  off 
about  2,300  calories.  This  amount  of  heat  must  be  replaced  by  his 
foodstuffs  to  keep  him  in  equilibrium. 

The  patient  with  rheumatism,  however,  is  suffering  from  fever,  and 
in  fever  he  gives  off  not  only  what  he  does  in  health  at  rest,  but  some  20 
to  30  per  cent.  more.  If  we  add  25  per  cent,  more  to  our  estimated 
calories  at  rest,  we  find  the  patient's  needs  are  2,800  to  2,900  calories. 
We  are  all  aware  that  in  febrile  conditions  it  is  customary  to  put  a 
patient  on  a  milk  diet,  because  the  different  food  constituents — fat, 
carbohydrates,  and  proteins — are  so  well  represented  in  it,  because  its 
protein  furnishes  all  the  elements,  amidobodies,  "building  stones," 
necessary  to  the  construction  of  body  protein  (which  is  not  true  of  all 
food  proteins),  because  it  is  bland,  and  because  it  is  easily  administered. 
The  physician's  instructions  frequently  are  a  glass  of  milk  every  two 
hours.  A  glass  is  supposed  to  hold  8  ounces;  more  commonly,  as  given,  it 
holds  6  ounces.  On  this  schedule,  ten  feedings  would  be  exceptional,  and 
eight  nearer  the  actual  number;  so  the  patient  would  get  1J^  to  2  quarts 
of  milk  a  day.  In  a  quart  of  milk  there  are  620  calories  of  food ;  in  the 
patient's  dietary,  930  to  1,240  calories,  or  one-third  to  two-fifths  of  his 
needs  as  calculated.  But  the  case  is  even  worse  than  this,  for,  as  I 
have  shown,  there  are  reasons  why,  in  fever,  a  patient's  dietetic  needs 
are  greater  than  those  set  out  above. 

It  is  an  easy  mathematical  problem  to  determine  chat  to  meet  the 
patient's  caloric  needs  with  milk  would  require  some  5  quarts  of  milk, 
and  the  administration  of  over  a  gallon  of  milk  day  after  day  does  not 
appeal  to  our  common  sense. 

Moreover,  this  amount  of  milk  would  contain  128  to  160  grams  of 
protein,  which  is  excessive. 

To  keep  within  quantitative  limits,  qualitative  changes  must  be 
made  in  the  food.  The  readiest  way  to  do  this  is  to  add  to  milk,  cream  to 
furnish  more  fat,  or  starch,  or  sugar,  to  furnish  more  carbohydrates. 
For  example,  enough  milk  sugar  can  be  added  to  the  milk  to  make  10 
per  cent,  without  making  it  disagreeably  sweet;  or  cereals,  to  make 


ACUTE  RHEUMATIC  FEVER  35 

gruels  or  milk  soups.  Six  per  cent,  of  sugar  added  to  milk  will  give  a 
milk  equal  to  about  860  calories  to  the  quart. 

In  addition  to  milk,  eggs,  cereals,  bread  and  butter,  rice,  and  cereal  or 
milk  soups  are  permissible.  An  ordinary  thick  slice  of  white  bread 
(1  1/3  ounces)  furnishes  100  calories;  an  average  pat  or  ball  of  butter 
(a  little  less  than  y%  ounce)  the  same;  an  ordinary  helping  of  boiled 
rice  (4  ounces)  as  much  more,  and  1  ^  to  2  ounces  of  cream  the  same. 
Three  even  teaspoonfuls  of  granulated  sugar  affords  100  calories.  There 
are  100  calories  in  a  large  serving  of  oatmeal  or  hominy,  and  one  egg  adds 
80  calories  more. 

This  necessity  for  a  sufficient  diet  obtains  especially  in  long-continued 
fevers,  while  in  the  brief  fevers  of  intense  character,  in  which  the  func- 
tions of  the  digestive  organs  are  impaired,  only  small  amounts  of  food 
are  to  be  urged,  as  the  body  has  a  surplus  to  meet  its  needs  for  a  short 
time. 

I  have  introduced  these  figures  to  concentrate  attention  on  a  branch 
of  our  art  that  has  been  left  too  little  cultivated  and  exercised  without 
reason.  Milk,  milk  soups,  cereals,  bread,  and  rice  form  the  staple  diet 
in  rheumatism.  To  meat  soups,  which  have  scarcely  any  nutritive 
value,  there  are  certain  theoretical  objections,  but  if  their  well-known 
influence  in  spurring  a  jaded  appetite  and  stimulating  what  the 
Germans  call  the  "appetit-saft,"  is  taken  into  consideration,  I  think 
their  administration  in  small  amounts  is  warranted.  With  the  decrease 
in  the  fever,  eggs  may  be  used;  and  in  convalescence,  fish,  meats,  and 
vegetables. 

Fluids.  Water  should  be  allowed  ad  libitum  unless  the  heart  is  de- 
compensated  in  which  case  certain  restrictions  should  be  made.  As  more 
grateful  drinks,  dilute  fruit  juices  are  permissible,  orangeade,  lemonade 
or  diluted  grape-juice.  See  diet  in  Summary. 

Bowels.  When  called  to  attend  a  patient  suffering  from  an  acute 
infectious  process,  it  is  a  good  rule  to  assure  satisfactory  evacuation 
of  the  bowels.  Just  how  much  additional  disturbance  a  neglect  of  this 
measure  may  induce  we  do  not  know,  but  we  are  aware  of  the  fact  that 
at  times  in  an  individual  otherwise  well,  constipation  may  incite  symp- 
toms akin  to  acute  intoxication,  or  more  commonly,  depression,  malaise, 
anorexia,  and  headache,  and  we  have  evidence  that  products  of  decom- 
position in  the  bowel,  normally  absorbed  and  paired,  like  the  indol  group, 
with  sulphuric  acid,  can,  when  this  function  of  pairing  is  interfered  with 
in  disease,  give  rise  to  toxic  manifestations. 

An  active  saline,  like  magnesium  sulphate  or  Epsom  salt,  sodium  sul- 
phate or  Glauber's  salt,  or  sodium  potassium  tartrate  or  Rochelle  salt, 
in  doses  of  1  ounce,  or,  in  patients  susceptible  to  saline  purgatives,  % 


36  TREATMENT  OF  ACUTE  INFECTIOUS  DISEASES 

ounce,  may  be  given,  assisted  by  a  soapsuds  enema  four  to  six  hours  later 
if  the  salts  have  not  been  sufficiently  effectual. 

"  Technique  of  a  Soapsuds  Enema.  The  enema  is  prepared  by  agi- 
tating white  castile  or  ivory  soap  in  warm  water  until  a  good  suds  is 
formed.  The  froth*  must  then  be  removed  because  it  contains  air  and,  if 
introduced  into  the  bowel,  may  cause  pain.  From  one  to  two  quarts  of 
soapsuds  are  used.  This  is  then  poured  into  a  douche  bag  or  fountain 
syringe  to  the  tubing  of  which  has  been  attached,  by  means  of  a  glass 
connecting  tube,  a  large  catheter  or  rectal  tube.  The  bed  should  be 
protected  by  a  rubber  sheet  and  the  patient  be  placed  in  the  dorsal 
recumbent  position,  the  pan  or  douche  bag  be  raised  to  a  distance  of  not 
over  three  feet  above  the  patient  and  in  order  to  avoid  getting  air  into 
the  intestines  the  fluid  should  be  allowed  to  run  through  the  tube  when 
it  is  undamped  before  introducing  it  into  the  bowel. 

"  The  rectal  tube  should  be  lubricated  with  vaseline  or  soap  emulsion 
and  introduced  slowly  into  the  bowel  to  a  distance  of  about  eight  or 
ten  inches. 

"  One  to  two  pints  for  a  child  or  2-4  pints  for  an  adult  should  be  al- 
lowed to  run  in  slowly,  the  flow  being  controlled  by  a  clamp  or  stop- 
cock attached  to  the  tubing. 

When  the  patient  begins  to  complain  about  discomfort  the  flow  should 
be  stopped  and  rectal  tube  should  be  removed  slowly  and  gently.  The 
patient  being  instructed  to  retain  the  enema  for  10-15  minutes."  (Pope 
and  Maxwell.) 

It  should  be  remembered  that  the  feces  represent  an  excretion  from 
the  bowel  of  mucus  and  other  substances  which  represent  nitrogenous 
metabolism,  as  well  as  a  large  content  of  bacteria,  and  afford  a  pretty 
constant  percentage  of  the  total  nitrogenous  output;  that  the  feces  are 
not  mere  food  residues,  and,  in  fact,  normal  feces  should  contain  but  very 
little  food  residue  other  than  indigestible  fibers  of  cellulose,  seeds,  etc. 
Hence  it  is  surprising  to  the  patient,  and  often  to  the  physician,  too,  to 
discover  so  large  results  from  catharsis  when  the  patient  has  been  on  a 
milk  diet,  or  even  when  on  no  diet  at  all.  With  this  knowledge,  then,  of 
the  formation  of  feces  with  a  low  or  easily  digestible  diet,  the  necessity  of 
attending  to  periodical  evacuation  is  emphasized.  This  may  best  be 
done  by  enemas  in  most  febrile  diseases,  but  with  the  discomfort  incident 
upon  handling  the  body  in  rheumatism,  further  doses  of  salines  may 
be  preferred.  I  believe  that  too  frequent  catharsis  by  drugs  entails  an 
irritation  that  in  itself  may  become  mischievous. 

Sleep.  Rest  cannot  be  guaranteed  unless  sleep  can  be  obtained.  Of 
first  importance  is  the  environment.  If  the  room  is  cool,  well  ventilated, 
the  patient's  toilet  prepared  for  the  night,  the  bed  arranged,  lights  turned 


ACUTE  RHEUMATIC  FEVER  37 

low  and  noise  excluded  much  will  have  been  done  to  secure  sleep.  If 
this  is  nob  effectual,  mild  hypnotics  may  be  tried  such  as  bromides  in 
doses  of  gr.  xv-xxx  (1-2  Gm.)  or  trional1  gr.  v  to  gr.  xv  (0.33-1  Gm.), 
or  chloralamid  gr.  xx-xxx  (1.33-2  Gm.)  early  in  the  evening,  often 
the  lesser  dose  will  be  found  to  be  effectual.  Adalin  in  gr.  v  (0.33  Gm.) 
doses  is  a  mild  hypnotic.  Barbital  (Veronal)  and  sodium  barbital 
(Medinal)  gr.  v-vii  ss.  (0.33-0.50  Gm.)  may  be  used,  but  are  not  favorites 
of  mine. 

All  too  often  sleeplessness  is  due  to  pain,  and  sleep  can  be  obtained  only 
by  an  anodyne.  One  may  use  codeine  phosphate  gr.  1/8  to  ss  (0.008- 
0.030  Gm.)  by  mouth  or  hypodermically,  or  in  severe  cases  morphine 
sulphate  gr.  1/8-1/4  (0.008-0.015  Gm.)  hypodermically.  The  doses 
given  are  for  adults  and  must  be  modified  for  children  according  to 
Young's  rule  or  adapted  to  weight.  Young's  rule  is  to  divide  the  age  of 

2 

the  child  by  theage+12;  e.  g.,  for  a  child  of  2  years =  1/7  there- 

2-|- 12 

fore  the  child's  dose  would  be  1/7  of  the  adult  dose. 
Weight  Rule.    Dr.  Clark's  rule  is  to  divide  the  child's  weight  by  150; 

50 

i.  e.,  if  the  child  weighs  50  pounds,  -  -  =  1/3,  therefore  the  dose  would 

150 

be  1/3  of  the  adult  dose. 

Cowling  divides  the  figure  of  the  next  birthday  by  24;  therefore  if  the 

O  1 

child  is  2,  —  =-,  therefore  the  dose  of  the  child  is  1/8  of  the  adult  dose. 

Specific  Treatment.  It  was  once  hoped  that  every  disease  might  be 
met  by  a  specific  drug,  and  it  was  once  believed  that  many  diseases  were 
cured  by  specific  drugs;  but  as  medicine  entered  on  an  era  of  more  search- 
ing observation,  and  had  to  rest  its  judgment  on  scientific  criteria,  the 
number  of  specifics  dwindled,  until  the  term  "specific  treatment"  has 
come  to  connote  the  treatment  of  one  disease  alone,  syphilis. 

The  Salicylates.  When  Dr.  Maclagan,  of  Edinburgh,  in  1874,  began 
to  use  salicin,  a  glucoside  of  salicylic  acid,  obtained  from  the  young  bark 
of  the  willow,  in  rheumatism,  which  was  quickly  followed  by  the  intro- 
duction of  other  forms  of  salicylic  acid,  the  change  that  came  over  the 
clinical  picture  of  this  disease,  that  turned  a  bed  of  racking  pain  into  a 
couch  of  relative  comfort  in  a  few  hours,  and  a  patient  to  whom  the  least 
touch  was  agonizing  into  one  who  could  be  handled  with  relative  impu- 
nity, warranted  the  belief  that  a  specific  had,  indeed,  been  discovered. 
It  is  said  that  we  no  longer  see  rheumatism  as  it  was  presented  to  the 

1  Trional  is  the  official  sulphonethyl  methane.  For  the  sake  of  brevity  trional 
is  used  throughout  the  book. 


38  TREATMENT  OF  ACUTE  INFECTIOUS  DISEASES 

older  practitioners,  and  yet  the  drug  cannot  be  called  specific,  if  we  mean 
by  that  one  that  can  eradicate  the  disease.     That  its  discovery  was  a 
boon,  no  one  who  has  witnessed  its  effects  can  for  a  moment  doubt. 
Salicylic  acid  has  this  structure: 

(I) 
H 

^C\ 
(6)HC  X         CR(2) 

I  II 

(5)HC^    XCH(3) 

C 
H 

(4) 

is  the  benzene  ring.  If  we  will  replace  the  H  at  (2)  by  an-OH  group, 
that  is,  make  an  alcohol  of  it,  we  convert  it  into  a  well-known  poison, 
carbolic  acid. 

H 


I  II 

HC.       /CH 

^CX 

H 

Note  what  slight  changes  in  a  complex  group  and  the  introduction  of 
what  simple  radicles  induce  potent  changes  in  character.  We  have  but 
to  make  another  slight  change,  by  introducing  an  acid  radicle  at  (I),  to 
convert  the  toxic  carbolic  acid  (which  is  no  acid  at  all,  but  an  alcohol) 
into  the  substance  in  question,  salicylic  acid.1 

COOH 

' 


HC^      XCH 

^CX 

H 

I  might  add  that  the  introduction  of  an  acid  radicle  into  the  structure 
of  a  toxic  alcohol  detoxicates  it.  This  is  a  general  law. 

This  substance  is  classed  among  the  antipyretics  and  antiseptics; 
it  is  also  an  anodyne.  Its  therapeutic  value  is  exercised  in  all  three 
directions  in  rheumatism.  Salicylic  acid  should  not  be  administered 
as  such,  but  in  the  form  of  a  salt  or  ester.  The  effect  is  the  same  in 
kind  in  all  these  forms,  but  certain  by-effects  determine  the  use  of  one 

1  Salicylic  acid  is  not  derived  in  this  manner,  but  from  ortho-oxy-benzyl  al- 
cohol, HO.C6H4.CH20H.  The  illustration  is  used  to  draw  attention  to  the 
chemical  kinship  of  well-known  drugs  which  are  so  different  in  their  action. 


ACUTE  RHEUMATIC  FEVER  39 

or  the  other.  It  should  be  administered  in  full  dose.  Its  failure  may 
often  be  attributed  to  insufficient  dosage.  Its  toxicity  is  slight.  In 
an  adult  of  average  weight  I  give  as  much  as  20  grains  (1.30  Gm.)  of  one 
or  the  other  form  of  the  drug  every  two  hours  for  the  first  twenty-four 
hours  during  the  waking  period,  or  even  for  forty-eight  hours.  In 
severe  cases  even  30  grains  (2  Gm.)  may  be  given  foi'  the  first  two  or 
three  doses.  As  the  pain  subsides  the  dose  may  be  cut  down  gradually  to 
15,  to  10  (1.-0.60  Gm.)  grains  at  a  dose,  how  much  and  how  rapidly 
depending  on  the  progress  of  events  or  on  signs  of  toxity.  The  dose 
should  be  well  maintained  at  amounts  of  10  grains  (0.60  Gm.)  every  two 
hours  until  the  active  phases,  as  evidenced  by  fever,  pain,  and  joint 
swelling,  have  passed.  Just  how  this  drug  acts  in  rheumatism  we  do  not 
know,  but  its  effects  are  so  much  more  prompt  and  satisfactory  in  this 
condition  than  in  any  other  clinically  akin  to  it,  that  we  are  tempted  to 
believe  that  it  has  some  effect  on  the  materies  morbi  directly.  It  is  my 
custom  to  keep  the  patients  on  considerable  doses — 5  to  10  grains  (0.30- 
0.60  Gm.)  every  two  or  three  hours  for  a  week  or  ten  days  after  the 
subsidence  of  acute  symptoms,  and  for  four  to  six  weeks  on  lesser  doses  of 
5  or  10  grains  (0.30-0.60  Gm.)  three  or  four  times  a  day,  administering 
the  drug  much  as  we  do  quinine  in  malaria. 

If  satisfactory  results  do  not  follow  these  doses  they  may  be  pushed 
to  the  production  of  toxic  manifestations. 

Hanzlik's  studies  of  the  toxicity  of  the  salicylates  carried  on  at  the 
request  and  under  a  grant  from  the  Committee  on  Therapeutic  Research, 
Council  on  Pharmacy  and  Chemistry,  American  Medical  Association, 
showed  that  the  toxic  dose  of  Sodium  Salicylate  in  the  majority  of  indi- 
viduals of  both  sexes  lies  between  100  and  200  grains  per  diem  (the  mean 
toxic  dose  for  males  nearer  200,  for  females  nearer  150). 

These  figures  are  close  to  my  customary  dosage. 

The  dosage  for  children  should  be  relatively  large  and  may  be  pushed 
to  toxicity,  even  in  cardiac  disease. 

The  tendency  is  to  give  to  children  too  small  a  dose  rather  than  too 
large.  When  men  of  large  experience,  like  Lees  in  England,  give  200- 
400  and  more  grains  a  day  to  children  under  sixteen  years,  it  will  be 
appreciated  how  far  short  of  the  danger-mark,  if  not  of  efficiency,  our 
usual  dosage  is. 

With  this  drug,  one  may  administer  an  alkali.  I  prefer  bicarbonate 
of  soda  of  which  something  more  than  grain  for  grain  should  be  given; 
my  rule  at  the  beginning  is  2  grains  of  bicarbonate  to  one  of  the  salicylate. 
It  seems  to  lessen  the  irritating  effect  of  the  salicylate  on  the  gastro- 
intestinal tract. 

The  toxic  symptoms,  except  such  as  constitute  an  idiosyncrasy  are 


40  TREATMENT  OF  ACUTE  INFECTIOUS  DISEASES 

disagreeable  rather  than  dangerous  or  disagreeable  long  before  they  are 
dangerous,  giving  ample  warning  to  watch  or  to  stop  or  modify  the 
dosage. 

They  are:  (1)  buzzing,  roaring  hi  the  ears,  with  varying  degrees  of 
deafness,  headache;  (2)  gastric  disturbances,  more  rarely;  (3)  cardiac 
disturbances;  (4)  respiratory  disturbances;  (5)  cerebral  symptoms; 
(6)  renal  complications;  (7)  hemorrhages;  and  (8)  skin  involvement. 
This  looks  like  a  formidable  array  of  disasters,  and  so  do  tidal  waves, 
cataclysms,  and  the  fall  of  meteors  in  the  catalogue  of  everyday  possi- 
bilities; but,  like  most  apparitions,  this  list  takes  less  substantial  propor- 
tion when  submitted  to  light.  I  will  consider  them  in  the  reverse  order. 
Skin  eruptions  after  the  use  of  the  salicylates  are  rare;  still  a  diffuse 
erythema,  an  urticaria,  a  hemorrhagic  outbreak,  and  other  forms  may 
follow.  It  will  be  observed  that  the  three  forms  specified  have  all  been 
associated  with  rheumatism,  and  it  would  be  difficult  to  determine  in  all 
cases  the  association  of  the  drug  with  the  rash.  They  are  not  dangerous 
in  themselves,  and  the  drug  should  not  be  intermitted  on  their  appear- 
ance unless  the  rash  is  distinctly  aggravated  by  the  continuance  of  the 
drug. 

Retinal  hemorrhages  are  still  more  uncommon,  while  epistaxis  and 
other  hemorrhagic  manifestations  have  been  more  frequently  reported, 
and,  if  severe,  might  enforce  cessation  of  the  drug.  Albuminuria  and 
hematuria,  which  have  been  attributed  to  the  irritating  effects  of  salicy- 
lates, may  be  and  probably  are  caused  by  the  disease  itself,  but  with 
their  appearance  it  might  be  wise  to  intermit  the  treatment  until  it  is 
demonstrated  that  they  do  or  do  not  play  a  part  in  the  disturbance. 
Scott  and  Hanzlik  have  recently  called  attention  to  the  appearance  of 
albumin,  leucocytes  and  small  granular  bodies  resembling  casts  in 
the  urine  of  patients  taking  salicylates;  they  note,  however,  that  this 
promptly  clears  up  after  salicylates  have  been  stopped. 

I  do  not  feel  that  these  statements  should  lead  to  the  modification  of 
our  salicylate  treatment  of  rheumatism  and  in  a  rather  large  experience 
in  these  cases  I  have  never  seen  renal  complications  from  this  cause  that 
were  clinically  recognizable  or  eventuated  in  renal  disease.  There  can  be 
no  doubt  that  now  and  then  the  salicylates  have  induced  an  active  delir- 
ium, sometimes  like  an  acute  mania.  I  recall  a  report  of  two  such  cases 
occurring  at  Bellevue  Hospital,  but  it  is  very  unusual.  It  must  not  be 
forgotten  that  delirium  intervenes  in  the  course  of  rheumatism,  espe- 
cially, it  is  said,  with  the  onset  of  a  pericardia!  involvement,  and  associ- 
ated with  hyperpyrexia.  Dyspnoea,  characterized  by  slow  and  labored 
breathing  (see  below),  has  occurred,  and  suggests  the  possibility  of  im- 
purities in  the  drug,  as,  indeed,  does  the  slow  heart  and  threatened 


ACUTE  RHEUMATIC  FEVER       ,  41 

collapse  occasionally  noted.  Here,  too,  one  must  keep  in  mind  the  in- 
volvement of  the  myocardium,  the  lung  and  the  pleura,  in  the  disease. 
However,  in  either  instance,  so  threatening  a  condition  should  indicate 
a  withdrawal  of  the  drug. 

I  have  recently  seen  four  cases  of  bradycardia  and  arhythmia  in 
rheumatism;  in  some  of  these  have  obtained  the  graphic  evidence  of  sino- 
auricular  block.  In  all  cases  the  block  disappeared  with  the  intermission 
of  the  salicylate  and  in  one  a  return  was  provoked  by  its  resumption. 
No  evidence  of  circulatory  embarrassment  was  seen  in  these  cases. 
Sino-auricular  block  has  been  reported  in  other  acute  infections  such  as 
influenza  in  which  no  salicylate  had  been  administered.  Auriculo- 
ventricular  block  has  been  repeatedly  noted  in  rheumatism  in  which  no 
salicylates  had  been  administered  and  has  been  attributed  to  inter- 
ference of  conduction  impulses  by  the  Aschoff  bodies,  the  characteristic 
lesion  in  rheumatism,  whose  site  of  election  is  in  and  about  the  conduct- 
ing bundle  of  His. 

To  sum  up,  I  should  say  that  the  above-mentioned  conditions  are 
rare;  that  they  may  be  attributable  in  most  instances  to  the  disease 
rather  than  to  the  drug,  or  to  idiosyncrasies — those  peculiar  reactions 
of  the  individual  to  drugs,  food,  and  environment  that  takes  him  out 
of  his  class  and  constitutes  in  him  an  anomaly,  and  defies  foreknowledge. 
I  firmly  believe  that  it  is  only  a  minority  of  the  above-mentioned  condi- 
tions that  can  be  attributed  to  the  drug  itself. 

It  stands  otherwise  with  the  first  two  disturbances  enumerated. 
They  are  to  be  attributed  to  the  drug,  and  their  occurrence  modifies 
our  action.  The  ringing  in  the  ears  and  a  mild  grade  of  deafness  may 
be  looked  upon  as  a  limit  of  tolerance  with  comfort  rather  than  a  menace. 
There  is  no  reason  to  intermit  the  drug  on  this  account,  but  if  the  dis- 
comfort is  considerable,  the  dosage  should  be  cut  down  or  stopped.  The 
gastric  irritation  resulting  upon  the  administration  of  salicylates  is  the 
bete  noir  of  the  practitioner.  It  is  for  this  reason  rather  than  for  any 
other  that  so  many  forms  of  salicylates  are  in  use.  There  are  certain 
forms  of  the  drug  from  which  one  may  anticipate  more  irritation  than 
from  others,  but,  again,  the  susceptibility  of  a  particular  stomach 
to  a  particular  preparation  cannot  be  predicted  with  any  degree  of 
assurance. 

I  advise,  as  a  rule,  the  use  of  the  preparation  that  has  stood  best 
the  test  of  time  and  experience.  In  this  case  it  is  the  sodium  salt  of  the 
acid,  sodium  salicylate.  I  may  say  at  once  that  the  acid  itself  is  too 
irritating  to  administer  internally.  Order  the  drug  alone,  in  simple 
solution.  Order  the  dose  to  be  taken  well  diluted. 


42  TREATMENT  OF  ACUTE  INFECTIOUS  DISEASES 

For  example,  write  thus : 

$ 

Sodii  Salicylatis 15.         gss. 

AqusB  destillatse  q.  s.  ad 60.         gij 

M.  et  S. — One  teaspoonful  in  water  every  two  hours. 

One  will  note  that  this  calls  for  a  2-ounce  mixture,  but,  if  written  in 
the  metric  system,  that  there  are  just  as  many  grams  in  this  2-ounce, 
or  60  c.c.,  mixture  as  we  want  to  give  grains  in  one  dose.  Even  the 
water  has  as  many  cubic  centimeters  as  we  want  to  give  drops  in  a 
dose — 60,  that  is,  1  teaspoonful. 

Sometimes  the  salt  is  better  borne  and  less  disagreeable  to  the  taste 
if  a  little  glycerin  is  used,  as: 

3 

Sodii  Salicylatis 15 . 

Glycerini 15 .          aa  5  ss. 

Aquae  destillatae  q.  s.  ad 60 .  5  ij 

M.  et  S. — One  teaspoonful  in  water  every  two  hours. 

If  one  has  doubts  about  his  patient's  ability  to  get  a  good  salt,  he 
should  order  the  salt  made  fresh  from  salicylic  acid  by  adding  sodium 
bicarbonate.  This  is  a  very  excellent  way  of  writing  the  prescription: 

9 

Acidi  Salicylici 15 .         5  ss. 

Sodii  Bicarbonatis q.  s.        q.s. 

Aquae  destillatae  q.  s.  ad 6Q.          5  ij 

M.  et  S. — One  teaspoonful  in  water  every  two  hours. 

The  druggist  is  to  use  of  the  soda  what  is  needed;  he  adds  definite 
proportions  of  the  two  drugs,  if  he  follows  the  Pharmacopoeia,  or  he 
simply  adds  soda  to  the  solution  of  the  acid  until  effervescence  ceases; 
that  is,  until  no  acid  is  left  to  liberate  the  carbon  dioxide  from  the  soda. 

In  the  early  days  of  the  synthesis  of  sodium  salicylate  a  good  many 
impurities  existed  which  made  such  a  prescription  as  was  just  cited 
a  wise  precaution,  but  Hilprit's  study  of  the  different  synthetic  sodium 
salicylates  at  the  instigation  of  the  Council  of  Therapeutic  Research 
of  the  A.  M.  A.  show  that  such  impurities  no  longer  exist  and  that 
their  "investigation  would  seem  to  warrant  the  conclusion  that  the 
cheapest  commercial  synthetic  sodium  salicylate  is  the  equal  of  the 
higher  priced  brands  of  the  synthetic  kind  or  costly  natural  product." 
.  If,  for  any  reason,  sodium  salicylate  is  not  well  borne,  one  may  have 
.recourse  to  another  form  of  the  drug.  Moreover,  it  has  been  occasion- 
ally noted  that  a  patient's  symptoms  which  did  not  yield  to  one  form  of 
salicylate,  may  to  another,  e.  g.,  to  aspirin  after  the  failure  of  sodium 
salicylate.  My  own  preference  is  for  acetylsalicylic  acid  [aspirin],  that 


ACUTE  RHEUMATIC  FEVER  43 

is,  salicylic  acid  in  which  the  H  of  the  OH  group  has  been  replaced  by  an 
acetic  acid  radicle,  CH3CO;  thus: 

COOH 

XCO.CH3CO 

II 
CH 

CX 
H 

This  substance  is  a  white  powder,  formed  of  small  crystalline  needles, 
practically  insoluble  in  water  (100  parts)  and  in  acids,  so  that  it  passes 
through  the  stomach  for  the  most  part  unchanged,  and  is  broken  up  in 
the  intestine.  It  is  less  irritating  to  the  stomach,  but  that  it  should  be 
devoid  of  all  the  disadvantages  of  the  sodium  salt  its  chemical  structure 
forbids  us  to  believe.  I  have  in  one  instance  seen  a  massive  angioneu- 
rotic  cedema  of  the  face  follow  a  single  small  dose,  and  have  seen  such 
cases  reported  in  the  literature  since.  However,  I  believe  it  to  be  a  very 
valuable  form  of  salicylic  acid.  It  is  best  prescribed  in  capsules.  The 
dose  is  practically  the  same  as  the  sodium  salt,  or  about  15  grains 
(1.0  Gm.)  for  a  beginning  dose. 

The  Committee  determined  the  mean  toxic  dose  of  aspirin  to  be 
a  little  smaller  only  than  that  of  sodium  salicylate,  i.  e.,  165  grains 
a  day  for  adult  males,  120  for  females. 

It  is  said  that  alkaline  salts  must  not  be  given  at  the  tune  of  adminis- 
tration because  they  decompose  the  drug  in  the  stomach  and,  therefore, 
should  be  given  between  the  doses.  As  Bastedo  has  pointed  out,  this 
is  more  or  less  a  theoretical  consideration  and  in  the  test-tube  bicarbon- 
ate of  soda  cannot  be  shown  to  decompose  the  drug.  He  finds,  indeed, 
that  the  administration  of  a  little  bicarbonate  of  soda  in  many  instances 
lessens  the  irritating  effects  of  the  drug  in  the  stomach. 

Another  excellent  preparation  of  the  salicylic  acid  series  is  the  ester, 
methyl  salicylate,  that  is,  salicylic  acid  in  which  the  H  of  the  acid  group 
is  replaced  by  methyl  CH3  ;  thus: 

COOCH3 

HC^  XC.OH 

I  II 

HC  CH 

^CX 
H 

Methyl  salicylate  is  a  volatile  oil  that  constitutes  well  over  90  per 
cent,  of  the  oil  of  wintergreen,  the  well-known  gaultheria  procumbens  of 
our  woods,  and  of  the  oil  of  birch,  oleum  betulse,  obtained  from  the  bark 
of  the  sweet  birch,  betula  lenta,  or  is  produced  synthetically,  and  when 


44  TREATMENT  OF  ACUTE  INFECTIOUS  DISEASES 

carefully  prepared  should  answer  the  purposes  of  the  natural  oils.  Of  the 
three,  the  oil  of  wintergreen  is,  as  a  rule,  preferred.  It  may  be  given  in 
capsules,  in  emulsion,  or  in  milk.  I  very  much  prefer  the  capsules, 
because  in  emulsion  the  decided  taste  of  the  drug,  which  may  be  agree- 
able at  first,  sooli  palls  on  the  patient. 

As  for  its  administration  in  milk,  the  same  objection  obtains,  and 
what  is  much  more  important,  it  violates  a  rule  that  I  believe  one  should 
invariably  observe — never  give  medicine  in  food,  for,  if  the  medicine  does 
disagree,  its  association  in  the  mind  of  the  patient  with  the  food  may 
produce  a  disgust  for  food  which  may  be  the  mainstay  of  the  case. 

The  Committee's  research  placed  the  mean  toxic  dose  as  120  minims 
of  the  oil  of  gaultheria. 

The  drug  is  usually  very  well  borne,  but  its  decided  taste,  even  when 
given  in  capsules  (for  the  slight  eructations  it  often  induces  is  a  constant 
reminder)  is  the  chief  drawback. 

Diplosal  is  a  form  of  salicylate  more  lately  come  into  use  and  as  its 
name  suggests  contains  two  salicylic  acid  radicles;  that  is,  it  is  a  salicylo- 
salicylic  acid  or  salicylic  ester  of  salicylic  acid,  formed  by  the  condensa- 
tion of  two  molecules  of  salicylic  acid,  the  H  of  the  acid  radical  of  one 
molecule  being  replaced  by  the  second  molecule  entering  by  its  phenol 
group  (OH)  at  (1);  thus: 

COOH 


o.oc 

I 

^c\ 


XJ.OH 

H  I  I' 

HC^    XCH 

H 

It  is  an  insoluble  powder  and  like  aspirin  is  little  affected  by  acids,  so 
is  supposed  to  pass  the  stomach  unchanged  and  like  the  aspirin  is  broken 
up  by  alkalis. 

It  is  best  given  in  capsules  and  alkali  should  not  be  given  with  the 
dose  but  between  the  doses. 

It  has  the  same  toxic  effects  as  other  salicylates  and  is  given  in  about 
half  the  dose  of  sodium  salicylate. 

Hanzlik's  studies  showed  the  mean  toxic  dose  per  day  was  100  grains 
for  adult  males  and  83  grains  for  adult  females. 

I  have  had  but  little  experience  with  this  particular  form  of  salicylate. 

One  will  rarely  have  to  choose  outside  of  one  of  these  four  forms  of 
salicylic  acid  in  the  treatment  of  rheumatism.  If  he  does,  the  great 


ACUTE  RHEUMATIC  FEVER  45 

probability  is  that  he  has  not  administered  these  forms  properly,  or  that 
the  patient  cannot  stand  salicylic  acid  in  any  form,  or  that  the  series  does 
not  meet  the  needs  of  this  particular  case. 

I  will  mention  two  other  well-known  preparations:  First,  the  original 
drug,  salicin.  This  is  a  glucoside,  which  can  be  split  up  by  acids  into 
grape  sugar  and  saligenin,  the  active  principle,  which  is  the  alcohol  from 
which  salicylic  acid  is  formed,  and  this  formation  of  the  acid  goes  on  in 
the  body  after  its  administration.  It  is  a  white  powder,  bitter  to  the 
taste,  rather  insoluble  in  water  (28  parts),  so  best  administered  in  cap- 
sules. It  is  well  borne,  and  by  many  preferred  for  children.  The  dose  is 
the  same  as  for  the  others.  Second,  another  ester,  phenylsalicylate, 
salol  that  is,  salicylic  acid  in  which  the  H  of  the  acid  group  is  replaced  by 
phenyl  C6H6;  thus: 

COO 

C/~1 
N.  >&M*> 


HC^    ^CH  HC^    XCH 

H  H 

It  is  a  white  powder,  almost  tasteless,  and  quite  insoluble  in  water. 
It  passes  through  the  stomach  for  the  most  part  unchanged,  and  is 
broken  up  in  the  intestine,  two-thirds  of  it  appearing  as  salicylic  acid 
and  one-third  as  carbolic  acid.  It  is  administered  best  in  capsules  or 
powders,  or  can  be  suspended  in  mucilage  of  acacia.  It  has  no  advantage 
over  the  other  forms  in  rheumatism,  and  has  the  disadvantage  of 
affording  only  two-thirds  of  its  weight  as  the  desired  substance,  while 
one-third  is  the  toxic  carbolic  acid,  which  can  produce  its  characteristic 
poisonous  symptoms  when  given  in  large  doses.  The  dose  is  about  the 
same  as  for  the  other  preparations. 

As  I  have  already  intimated,  some  patients  cannot  take  salicylic 
acid  in  any  form.  We  cannot,  for  that  reason,  neglect  their  need  for 
relief  of  pain.  The  three  drugs  in  most  common  use  for  such  a  purpose 
are  acetanilid  (antifebrin),  antipyrin,  and  acetphenetidin  (phenacetin) 
(officially  acetphenetidinum).  Of  these  three,  the  first  is  the  most 
potent,  also  the  most  irritating  and  toxic.  These  drugs  are  not  given 
over  a  long  period,  as  the  salicylates  are,  but  as  needed,  to  control  pain. 
Often  small  doses,  frequently  repeated,  are  as  efficacious  as  fewer  large 
doses.  Acetanilid  may  be  given  in  doses  of  1J/2  grains  (0.1  Gm.)  every 
half  hour  for  four  doses,  or  2  to  3  grains  (0.15-0.2  Gm.)  every  two  hours. 
If  there  are  heart  complications,  it  should  not  be  used.  Phenacetin  may 
be  used  in  twice  the  dose.  The  dose  of  antipyrin  lies  between  the  two. 
These  drugs  should  be  promptly  stopped  if  cyanosis  appears,  which  is 


46  TREATMENT  OF  ACUTE  INFECTIOUS  DISEASES 

well  before  cardiac  or  respiratory  failure  threaten,  and,  of  course,  as  soon 
as  pain  is  relieved. 

If  the  pain  is  severe,  rather  than  push  these  coal  tars  to  large  doses, 
one  should  use  morphine,  in  small  doses,  hypodermically,  1/16  to  1/8 
grain  (0.004-0.008  Gm.),  of  the  sulphate.  Morphine  in  any  illness  of 
length  should  be  used  reluctantly  and  in  minimum  dose,  lest  a  habit  be 
established.  Two  other  drugs  have  been  much  used  to  control  pain — 
potassium  iodide  and  colchicum.  Their  bad  effects  on  the  stomach  are 
too  certain,  and  their  beneficial  effects  on  the  condition  too  dubious,  to 
encourage  their  use. 

Another  line  of  treatment,  originated  in  England  by  Fuller  to  combat 
an  acidity  that  at  that  time  was  looked  upon  as  an  etiological  factor  in 
the  disease,  is  the  "alkaline  treatment."  This  treatment  met  with  little 
favor  elsewhere  in  Europe,  but  was  adopted  in  this  country  to  a  consider- 
able extent,  and  still  has  some  vogue.  By  many  men  it  is  used  when  the 
salicylates  are  not  well  borne;  by  others  when  cardiac  complications 
threaten  or  exist;  and  by  a  very  great  many  in  conjunction  with  the 
salicylate  treatment.  Its  use  rests  on  empiricism  solely. 

One  should  choose  the  milder  alkalis — sodium  bicarbonate,  potassium 
citrate,  or  potassium  acetate;  for  example,  2  grains  to  1  of  salicylate  until 
the  urine  reacts  alkaline,  and  then  in  a  little  less  dose,  or  enough  to 
continue  the  urine  alkaline. 

Acidosis.  Miller  of  London  has  laid  a  great  stress  upon  the  dangers 
of  acidoses  that  may  obtain  with  the  administration  of  salicylates  which, 
if  it  were  true  would  be  a  matter  of  serious  consideration.  Recent  work 
of  Hanzlik,  however,  does  not  corroborate  these  findings  as  he  was 
unable  to  determine  on  the  administration  of  toxic  doses  of  salicylates 
that  the  reserve  alkalinity  of  the  blood  was  in  any  way  perceptibly 
altered.  One  should  be  warned  that  the  usual  ferric  chloride  test  for 
diaeetic  acid  in  the  urine  of  patients  taking  salicylates  elicits  a  beautiful 
purple  color  in  the  urine  that  without  control  may  be  mistaken  for  the 
rich  port-wine  red  of  the  diaeetic  acid  reaction. 

Vomiting.  Miller  studying  vomiting  in  children  taking  salicylates 
found  it  severe  in  only  10  per  cent,  of  the  cases  and  what  is  of  great 
importance  that  two-thirds  of  these  had  severe  cardiac  dilatation,  and 
drew  the  conclusion  that  vomiting  depended  less  on  the  dose  than  on 
involvement  of  the  heart  and  that  the  more  severe  the  heart  affection 
the  less  the  salicylate  required  to  induce  vomiting.  Small  doses  of  bro- 
mides combined  with  the  salicylates  may  lessen  the  gastric  irritation. 

It  must  be  remembered  that  vomiting  may  be  the  symptom  of  cardiac 
involvement  when  no  salicylates  are  taken  and  that  cardiac  involvement 
does  not  contra-indicate  the  use  of  salicylates,  but  it  is  well  to  divide  the 


ACUTE  RHEUMATIC  FEVER  47 

total  day's  dose  into  smaller  and  more  frequent  dosage,  or  use  the  rectal 
or  intravenous  methods. 

Rectal  Administration  of  the  Salicylates.  Heyn  of  Cincinnati 
called  attention  to  this  mode  of  administration  in  1912.  I  have  used 
it  with  trivial  modifications  with  most  gratifying  results  over  a  long 
period  of  time. 

The  essence  of  the  procedure  is  to  give  the  drug  in  suspension  in 
starch  paste  with  enough  opium  to  lessen  rectal  irritation  and  assist 
in  retention.  Give  a  cleansing  enema. 

Technique.  Make  a  thin  starch  paste — use  it  at  body  temperature. 
Take  4  to  6  ounces  (not  an  amount  too  large  to  be  retained  readily)  and 
add  to  it  1/2  to  total  daily  dose,  say  3i-ij  (4-8  Gm.)  of  the  sodium  salicyl- 
ate  in  powder  and  one  or  two  minims  (0.06-0.13  c.c.)  of  the  tincture  of 
opium.  Inject  gently  into  the  bowel  and  hold  the  buttocks  together  for 
a  few  moments.  Repeat  at  12-hour  intervals. 

Instead  of  dividing  the  dose  one  may  give  the  whole  dose  in  one 
daily  injection. 

The  amount  of  salicylates  used  depends  on  the  same  consideration  as 
when  given  by  mouth,  i.  e.,  to  the  point  of  efficiency  or  toxicity.  The 
amount  of  starch — enough  to  carry  the  drug  and  not  provoke  a  move- 
ment; the  amount  of  opium — the  least  to  effect  retention. 

Alkalis  (bicarbonate  of  soda)  should  be  given  in  same  amounts  by 
mouth  as  if  the  salicylates  were  so  administered. 

Intravenous  Administration.  Still  another  method  of  administering 
salicylates,  the  intravenous,  I  recommend  on  the  advocacy  of  my  col- 
league, Conner,  of  New  York,  although  I  am  entirely  lacking  in  personal 
experience  with  it.  Conner  does  not  urge  it  in  preference  to  the  more 
time-honored  mode  of  administration,  but  in  those  cases  where  success 
has  not  followed  the  latter  or  the  stomach  rejects  it.  I  simply  quote  in 
substance  and  largely  in  words  his  technique  as  published  in  The  Medical 
Record,  February  21,  1914. 

The  drug  chosen  is  a  chemically  pure  crystalline  sodium  salicylate 
dissolved  in  distilled  water  (preferably  recently  distilled)  which  has 
been  freshly  sterilized  by  boiling,  to  a  20  per  cent,  solution.  Such  a 
solution  will  keep  well  several  days  if  protected  from  the  light  and  will 
remain  colorless. 

A  rubber  ligature  is  placed  around  the  arm  tight  enough  to  obstruct 
the  venous  flow,  making  the  veins  at  the  bend  of  the  elbow  stand  out 
prominently.  The  desired  result  is  more  effectually  attained  if  the  arm 
is  allowed  to  hang  down  and  the  fist  is  opened  and  closed. 

The  skin  over  the  vein  is  then  sterilized  by  painting  with  Tincture  of 
Iodine.  The  best  syringe  to  use  is  one  made  entirely  of  glass,  holding 


48  TREATMENT  OF  ACUTE  INFECTIOUS  DISEASES 

10  c.c.  and  supplied  with  a,  fine  (small,  bright,  sharp)  hypodermic  needle. 
These,  of  course,  are  sterilized. 

The  arm  is  extended  fully  and  fixing  the  vein  below  by  pressure  with 
the  left  thumb,  the  operator  thrusts  the  needle  intq,the  vein  in  the  direc- 
tion of  the  venous  flow,  and  makes  certain  of  entrance  into  the  vein  by 
drawing  a  drop  of  blood  into  the  syringe;  and  then  injects.  Pressure  is 
made  for  a  moment  over  the  site  of  the  injection  to  prevent  leakage  of 
blood  into  the  subcutaneous  tissue  and  the  iodine  washed  off  with 
alcohol. 

Fifteen,  twenty,  or  even  thirty  grains  are  given  at  12  or  8  hour 
intervals.  No  unpleasant  effects  were  met  with  in  Dr.  Conner's 
experience,  even  after  120  grains  a  day. 

The  relief  from  pain  is  striking  and  prompt  and  the  stomach  is  not 
upset. 

The  same  vein  can  be  used  again  and  again,  provided  a  small  clean 
needle  is  used. 

Symptomatic  Treatment.  The  symptoms  that  give  character  to  this 
disease  are  those  referable  to  the  joints.  The  improvement  in  the  local 
manifestations  of  the  disorder  under  salicylates  constitutes  one  of  the 
most  satisfactory  evidences  of  their  potency,  and  yet  the  resolution  of 
these  parts  often  lingers  well  behind  the  disappearance  of  the  fever  and 
the  pain;  and,  moreover,  much  can  be  done  during  the  height  of  the 
disturbance  to  ameliorate  the  discomfort,  hasten  the  resolution,  and 
prevent  bad  sequels. 

Rest.  For  an  inflamed  joint,  just  as  for  a  broken  bone,  rest  is  impera- 
tive. Pain,  which  I  have  said  is  Nature's  agent,  impels  rest,  but  when 
pain  is  banished  or  mitigated  under  our  ministrations,  the  patient  uses 
the  joint  too  early,  and  often  to  his  great  detriment.  The  position  of  the 
limb  in  semiflexion  is  one  involuntarily  chosen  as  the  most  comfortable, 
and  may  be  preserved  during  the  acuteness  of  the  attack.  Various 
devices  are  used  to  maintain  a  single  position.  We  can  bolster  the  limb 
by  putting  pillows  under  the  knee  or  on  either  side,  or  accomplish  the 
same  by  the  use  of  the  Gatch  bed,  and  find  similar  arrangements  for  the 
other  joints.  This,  of  course,  cannot  assure  a  high  degree  of  immobility, 
and  we  can  secure  better  results  with  splints,  well  padded  and  carefully 
applied.  The  success  of  these  devices  depends  on  the  care  and  skill 
with  which  they  are  applied,  and  if  simply  suggested  by  you  and  left  to 
the  devices  of  unskilled  hands  in  the  application  will  be  far  worse  than 
useless.  Still  another  way  to  attain  the  desired  end  is  by  applying  stiff 
bandages  of  plaster-of-Paris  or  starch.  Again,  much  care  must  be  taken 
in  the  application,  as  the  parts  cannot  be  daily  inspected,  and  rough  folds 
in  the  bandage,  bits  of  dried  plaster  next  the  skin,  which  is  moist  with 


ACUTE  RHEUMATIC  FEVER  49 

the  excessive  perspiration,  can  induce  sores  of  serious  import.  These 
casts  must  be  reapplied  as  the  effusion  in  the  joint  disappears. 

In  a  considerable  experience  with  rheumatism,  I  have  very  rarely 
had  to  have  recourse  to  splints. 

The  joints  should  be  protected  by  some  material  that  prevents  chill- 
ing or  rapid  changes  of  temperature,  such  as  flannel  bandages.  At 
the  Presbyterian  Hospital  in  this  city  (New  York)  a  layer  of  cotton 
1-1  1/2  inch  thick,  covered  with  gauze  is  wrapped  around  the  joint  like  a 
binder  and  secured  with  safety  pins.  This  affords,  as  Well,  easy  access 
to  the  parts.  (Swift.) 

Heat  and  Cold.  The  patient's  testimony  is  sufficient  evidence  of 
the  comfort  these  measures  afford,  whatever  opinion  may  be  entertained 
with  reference  to  their  curative  qualities  and  the  rationale  of  their  action. 
From  the  standpoint  of  comfort  the  reaction  of  different  patients  to  heat 
or  to  cold  differs  widely.  To  one  patient,  with  a  painful  joint,  eold  gives 
almost  instant  relief,  while  in  another  the  pain  is  intensified,  and  finds 
relief  from  heat,  and  vice  versa.  Continuous  cold  exercises  considerable 
anesthetic  effect,  and  may  be  secured  by  the  application  of  the  ice  coil, 
or  the  more  readily  obtained  and  manipulated  ice  bag.  Ice  bags  of 
various  shapes  may  be  obtained,  but  the  circular  ice  bag  does  well  for 
most  purposes.  The  ice  bag  must  be  properly  filled  in  order  to  make  its 
application  efficient.  The  ice  should  be  cracked  in  pieces  not  larger  than 
the  end  of  one's  thumb,  and  enough  to  cover  the  bottom  of  the  bag. 
Enough  cold  water  is  poured  on  this  to  enable  one  to  force  all  the  air  out 
of  the  bag  and  screw  the  cap  down  to  the  level  of  the  water.  This  pro- 
cedure leaves  the  bag  supple,  so  that  it  may  be  wrapped  around  the 
part,  which  the  presence  of  air  makes  impossible.  Protect  the  part  with 
a  thin  layer  of  vaseline  or  oil  and  a  thin  layer  of  cloth.  A  long-con- 
tinued direct  application  of  ice  to  the  skin  may  do  damage  to  that 
structure.  Heat  is  best  applied  by  fomentations.  A  couple  of  layers  of 
flannel  are  wrung  out  of  boiling  water  in  a  wringer  made  of  a  crash 
towel,  and  applied  snugly  to  the  joint.  This  is  repeated  three  or  four 
times,  at  intervals  of  ten  to  fifteen  minutes.  The  parts  are  then  sponged 
with  water  at  about  75°  F.,  and  wrapped  in  flannel  or  non-absorbent 
cotton.  A  soothing  application  is  the  cold  compress.  This  is  done  by 
wringing  two  or  more  layers  of  linen  or  old  cotton  cloth  or  cheesecloth  out 
out  of  water  at  about  60°  F.  and  applying  snugly  to  the  part.  This  in 
turn  is  covered  by  dry  flannel.  These  applications  are  renewed  about 
once  an  hour.  The  effect  of  cold  is  momentary;  the  vessels  soon  dilating 
and  conveying  heat  to  the  surface,  warm  the  compress  to  the  tempera- 
ture of  the  part  drying  it.  The  reaction  induces  a  hyperemia,  the  value 
of  which  will  be  touched  on  at  some  future  time.  The  joints  should  at  all 


50  TREATMENT  OF  ACUTE  INFECTIOUS  DISEASES 

times  be  well  protected  from  changes  in  temperature.  This  is  best  done 
by  wrapping  them  in  layers  of  non-conducting  material,  like  flannel  or 
non-obsorbent  cotton  or  cotton  batten.  The  number  of  drugs  that  have 
been  used  locally  are  legion.  I  will  purposely  refrain  from  mentioning 
more  than  one  or 'two  that  I  have  found  helpful.'  Perhaps  the  most 
common  application  is  methyl  salicylate.  That  it  does  any  more  than 
any  other  volatile  oil,  by  inducing  a  hypermia,  I  doubt.  That  the  salicyl- 
ates  may  be  absorbed  by  the  skin  I  have  proved  to  my  own  satisfaction, 
but  not  in  such  amounts  as  to  make  that  the  object  of  the  applica- 
tion. The  methyl  salicylate  may  be  applied  pure,  or  in  the  form  of 
an  ointment.  The  following  is  one  in  much  use: 

« 

Methylis  Salicylatis -. f 5i          (4) 

Mentholis 5i         (4) 

M.  et-adde 

Petrolati  q.  s.  ad. . . , 5i        (30) 

Tere  bene  simul. 

Sig. — Apply  as  directed 

An  ointment  containing  ichthyol  has  been  much  praised.  For 
example: 

3 

Ichthyolis 5ii         (8) 

Petrolati  q.  s.  ad 3i        (30) 

M. 

Sig. — Apply  as  directed. 

Counterirritation.  Counterirritation  is  a  very  old  remedial  measure 
which  has  survived  the  rise  and  fall  of  countless  therapeutic  efforts,  and 
the  very  persistency  of  which,  in  this  Nihilistic  age,  speaks  for  its  reality. 
It  is  indicated  rather  in  the  subacute  stages  of  joint  inflammation  than 
in  the  acute.  Of  the  many  means  of  inducing  it,  I  will  mention  two  only 
as  worthy  consideration — the  cautery  and  the  fly  blister.  Of  the  two, 
the  former  is  much  the  better,  as  being  easier  of  application,  easier  of 
control,  less  likely  to  be  followed  by  bad  results  locally,  and  entailing  no 
danger  from  absorption.  The  cautery  is  flicked  lightly  over  the  part, 
care  being  taken  to  avoid  severe  blistering  or  deep  burns.  The  part  is 
then  smeared  with  vaseline,  oil,  or  ointment. 

In  applying  the  blister  (ceratum  cantharadis) ,  it  is  cut  about  one  inch 
square.  In  making  the  application  to  the  knee,  four  such  might  be  used, 
one  above  and  one  below  on  either  side.  Shave  and  cleanse  the  part. 
Oil  the  edges  of  the  blister  and  apply  a  little  vaseline  to  the  skin  adjacent 
to  the  blister,  to  avoid  its  spreading.  Leave  the  blister  in  position  for 
four  to  six  hours,  and  if  a  blister  has  not  formed  in  the  skin  by  this  time 
apply  a  warm  poultice  to  the  part,  which  will  hasten  its  formation. 


ACUTE  RHEUMATIC  FEVER  51 

Puncture  the  blister  on  its  dependent  edge,  evacuating  the  serum  but  not 
destroying  the  protecting  epithelium..  Dress  with  oil.  Some  of  the 
disadvantages  of  the  blister  have  just  been  set  forth,  and  in  the  presence 
of  a  damaged  kidney,  as  may  occur  in  the  course  of  rheumatism,  the  dan- 
gerous irritating  effect  of  this  drug  on  the  parenchyma  of  the  kidney, 
which  it  causes  in  the  course  of  its  excretion,  must  be  kept  in  mind. 

Pressure.  When  an  effusion  is  slow  to  absorb,  one  may  hasten  the 
result  at  times  by  applying  a  snug  bandage  of  flannel  or  rubber,  which 
will  exert  a  continuous  but  moderate  pressure. 

In  persistent  effusions,  and  effusions  will  sometimes  persist  after  both 
temperature  and  pain  have  ceased,  and  in  the  acute  stage  with  excessive 
and  painful  effusion  a  paracentesis  is  indicated. 

PARACENTESIS  OF  THE  KNEE-JOINT 

"  In  synovitis  the  joint  is  considerably  distended  and  there  are  four 
prominences  about  the  patella,  two  on  each  side,  above  and  below. 
The  upper  inner  swelling  is  usually  the  most  prominent  as  there  is 
more  space  for  the  collection  of  fluid  in  this  situation.  In  aspirating 
fluid  from  the  knee-joint  the  object  is  to  insert  the  needle  so  as  to 
be  sure  to  get  the  fluid  and  at  the  same  time  to  give  the  least  opportunity 
for  damage  to  the  joint  cartilage.  These  objects  are  best  attained  in 
either  one  of  the  upper  swellings.  My  personal  preference  is  for  the 
upper  inner  one.  The  aspirating  needle  should  be  from  8  to  10  cm.  long. 
It  should  be  of  moderate  calibre  and  should  have  a  point  not  too  long  and 
sharp.  It  should  have  an  obturator  so  that  one  may  assure  himself  of 
the  patency  of  the  needle  when  in  the  joint  cavity.  The  joint  is  painted 
with  tincture  of  iodine  over  a  space  5  cm.  in  diameter  with  its  centre  at 
the  site  of  puncture.  It  goes  without  saying  that  the  operator's  hands, 
the  needle  and  everything  used  must  be  scrupulously  sterilized.  The 
needle  is  held  firmly  in  the  operator's  hand  with  the  index  finger  on  the 
shaft  of  the  needle  about  4  cm.  from  its  point.  The  base  of  the  needle 
rests  in  the  palm  of  the  hand  so  that  it  is  used  somewhat  after  the  manner 
of  a  shoemaker's  awl.  With  the  thumb  and  index  finger  of  the  other 
hand  the  operator  steadies  the  skin  at  the  site  of  puncture.  The  skin  at 
the  site  of  puncture  may  be  previously  anaesthetized  by  injecting  a  few 
drops  of  novocaine  1  per  cent.  If  the  skin  appears  to  be  tough,  as  it  is  in  a 
certain  proportion  of  instances,  a  sharp  pointed  scalpel  may  be  used  to 
puncture  the  skin  after  the  novocaine  has  been  injected.  This  renders 
the  insertion  of  the  needle  very  much  easier,  as  it  is  always  the  skin  which 
gives  most  resistance.  The  needle  is  inserted  in  a  direction  upward, 
inward  and  backward  through  a  point  at  the  summit  of  the  swelling.  By 


52  TREATMENT  OF  ACUTE  INFECTIOUS  DISEASES 

following  this  course  upward,  backward  and  inward,  one  gets  into  the 
joint  obliquely  and  there  is  less  likelihood  of  damaging  the  articular 
cartilage  of  the  inner  condyle  of  the  femur.  There  is  always  plenty  of 
effusion  in  this^neighborhood  for  aspiration  and  when  the  needle  is  later 
withdrawn  the  oblique  entrance  into  the  joint  causes  a  valve  effect  so 
that  there  is  ho  leakage  of  the  infectious  material  into  the  periarticular 
structures.  After  the  needle  has  been  inserted  into  the  joint  sufficient 
fluid  for  the  purpose  of  examination,  culture,  etc.,  is  obtained.  While 
the  needle  is  in  the  joint  it  is  well  worth  while  to  entirely  evacuate  the 
fluid  contents  as  this  will  give  great  relief  to  the  patient's  symptoms  for 
a  time.  At  the  end  of  the  procedure  the  needle  is  withdrawn  in  the  line 
of  its  insertion,  a  small  sterile  pad  is  placed  over  the  puncture  hole,  and 
the  entire  joint  is  wrapped  in  a  bandage  which  causes  moderate  com- 
pression." (Personal  communication  from  Dr.  Alfred  S.  Taylor.) 

Often  the  effusion  will  not  recur  in  the  subacute  cases,  while  the  relief 
to  the  patient  in  the  acute  cases  is  highly  gratifying.  The  procedure, 
simple  as  it  is,  should  be  hedged  about  by  all  the  precautions  of  a  major 
operation,  for  an  infection  of  the  joint  by  a  pyogenic  organism  is  a  serious 
matter. 

If  paracentesis  be  done  and  the  opportunity  affords,  cultures  of  the 
aspirated  fluid  should  be  made  for  the  identification  of  the  organism  and 
its  use  as  a  vaccine.  Personally,  I  have  been  very  rarely  rewarded  by 
culture  of  the  joint  fluid  in  the  acute  cases. 

Later  Measures.  Chronic  rheumatism  is  spoken  of  by  both  the 
layman  and  the  physician  as  of  common  occurrence.  In  truth,  chronic 
rheumatism  as  a  sequence  of  true  acute  rheumatism  is  a  rarity.  Some 
men  believe  it  never  occurs  and  for  a  time  I  was  of  this  opinion;  but 
recent  studies  in  my  wards  have  convinced  me  that  it  is  an  occasional 
happening.  If  it  does  occur  care  must  be  exercised  to  prevent  ankylosis. 
Splints  must  be  occasionally  removed  and  plasters  and  bandages  taken 
off.  Gentle  manipulation  of  the  joint  must  be  carried  out;  or  intelligent 
massage,  hot  fomentations,  hot  air  baths,  and  baking  had  recourse  to 
to  facilitate  absorption  and  resolution.  In  these  later  stages  it  is  still 
believed  that  the  iodide  of  potassium  may  do  good. 

Better  in  my  estimation  is  the  use  of  vaccines  (see  below). 

COMPLICATIONS 

Hyperpyrexia.  The  sudden  onset  of  excessively  high  tempera- 
ture, with  extreme  restlessness,  headache,  vomiting,  delirium,  and 
later  coma,  suggestive  of  meningitis,  while  occurring  in  the  course 
of  other  febrile  processes,  is  relatively  common  in  rheumatism.  It 


ACUTE  RHEUMATIC  FEVER  53 

must  be  treated  promptly  and  on  the  same  principle  as  a  sunstroke, 
that  is,  by  a  rapid  withdrawal  of  heat.  This  is  effectually  done  only 
by  the  use  of  cold  baths  or  packs.  The  patient  is  put  into  a  tub  at  65°  F., 
or,  if  the  shock  is  too  great,  the  water  may  be  warmed  to  80°  F.,  and  as 
the  water  warms  from  the  patient's  body  heat,  the  temperature  is  kept 
down  by  adding  ice  to  it.  The  patient  should  be  kept  in  the  bath  until 
the  temperature  falls  several  degrees.  If  a  fall  to  about  102°  F.  can  be 
attained,  the  patient  should  be  removed  from  the  bath,  as  the  tempera- 
ture will  often  continue  to  fall.  During  the  bath,  ice  or  cold  water  should 
be  applied  to  the  head.  The  bath  should  be  repeated  as  often  as  the 
temperature  rises  to  between  104°  F.  and  105°  F.  If  the  patient  becomes 
chilled,  is  cyanosed,  the  temperature  falls  well  below  normal,  or  collapse 
threatens,  he  should  be  removed  from  the  bath,  put  in  warm  blankets, 
heat  applied,  and  stimulants  freely  used.  A  cold  pack,  the  wet  sheet 
in  which  the  patient  is  wrapped  being  continuously  rubbed  with  pieces 
of  ice  until  the  desired  drop  is  obtained,  is  sometimes  quite  as  efficacious 
as  the  bath. 

The  delirium  that  accompanies  hyperpyrexia  may  be  ameliorated 
or  controlled  by  the  measures  just  advised  for  that  condition.  If,  how- 
ever, the  delirium  still  continues  one  may  try  hyoscine  hydrobromate 
in  doses  of  gr.  1/200  to  1/150  (0.0003-0.00045  Gm.)  provided  that  the 
heart  is  not  involved;  or  better  yet  morphine  in  doses  of  gr.  1/8  to  gr.  1/3 
(0.008  to  0.02  Gm).  These  are  adult  doses.  A  measure  which  one 
frequently  has  recourse  to  in  the  treatment  of  delirium  in  acute  infectious 
diseases  with  very  excellent  result  is  Lumbar  Puncture;  for  the  technique 
of  which  see  Cerebro-spinal  meningitis,  Chap.  XXII. 

There  may  be  in  these  cases  a  serious  meningitis  with  increased  in- 
tracranial  pressure  or  one  may  assume  that  the  toxins  of  the  disease  are 
irritating  the  meninges  which  find  relief  on  withdrawal  of  the  cerebro- 
spinal  fluid  containing  toxins. 

Cardiac  Complications.  The  frequency  of  these  complications, 
and  their  gravity,  threatening  not  merely  the  patient's  life  in  the  pres- 
ent attack,  but,  worse  yet,  his  future,  dooming  him  to  a  life  of  invalid- 
ism  and  dependence,  make  them  by  far  the  most  important  features  of 
the  attack,  and  haunt  the  physician  from  the  incipiency  of  the  disease. 
A  visit  should  never  be  completed  without  a  careful  examination  of  the 
heart.  Changes  in  rate,  rhythm,  quality  of  sounds,  or  the  appearance  of 
adventitious  sounds,  should  immediately  put  the  physician  on  his  guard. 
It  cannot  be  too  emphatically  insisted  that  the  mildest  attack,  as  judged 
by  fever,  pain,  joint  implications,  and  general  discomfort,  may  still  be 
accompanied  by  grievous  heart  complications. 

Statistics  vary,  but  from  reliable  sources  it  is  gathered  that  peri- 


54          "  TREATMENT  OF  ACUTE  INFECTIOUS  DISEASES 

carditis  occurs  in  15  per  cent,  of  the  cases,  and  endocarditis  in  over 
50  per  cent.;  in  children  under  ten  years,  in  as  high  as  75  to  80  per  cent. 

Lees  insists  that  in  every  case  of  rheumatism  dilatation  of  the  left 
ventricle  can  be  made  out.  It  is,  he  says  "an  inevitable  manifesta- 
tion of  the  disease  and  one  of  its  earliest  sifanptoms"  (British  Med. 
Journ.,  October  12, 1912),  and,  certainly,  the  more  one  gives  attention  to 
alteration  of  cardiac  sounds  and  outline  the  more  convinced  he  is  of  the 
very  high  per  cent,  of  cardiac  involvement. 

It  must  be  remembered  that  a  more  proper  term  for  what  actually 
exists  in  the  heart  is  pancarditis,  for  the  whole  structure  is  likely  to  be 
implicated.  The  treatment  of  these  conditions  is  the  same  as  when 
occurring  under  other  circumstances,  and  I  will  merely  add  that  when 
there  are  signs  of  cardiac  decompensation  I  am  a  firm  believer  in  the  use 
of  the  digitalis  series  in  the  acute  cardiac  disease  in  the  same  large  doses 
as  in  the  chronic  form.  The  only  question  to  be  discussed  at  this  juncture 
is  the  use  of  salicylates.  Some  authors  fear  the  depressing  effects  of  the 
drug.  Others  still  consider  that  the  appearance  of  the  cardiac  complica- 
tions indicates  no  change  in  the  treatment.  Personally,  I  have  always 
continued  the  salicylates;  and  in  the  same  liberal  doses  as  in  uncompli- 
cated cases. 

I  have  never  been  convinced  of  any  bad  results  by  so  doing  unless 
the  rare  occurrence  of  the  bradycardia  mentioned  be  called  such.  If 
salicylates  have  any  effect  on  the  disease  organisms  themselves,  it 
would  seem  as  if  their  use  in  the  serious  complications  of  the  disease  was 
the  more  urgent. 

Any  case  of  rheumatism  in  whom  a  cardiac  complication  is  evident 
should  be  kept  in  bed  two  months,  even  though  joint  manifestations 
and  temperature  promptly  disappear,  and  as  much  longer  as  the  cardiac 
condition  and  symptoms  of  the  infection  continue. 

While  cardiac  murmurs  have  great  significance,  they  need  not  neces- 
sarily be  present  when  the  heart  is  affected;  hence,  the  great  importance 
of  familiarity  with  the  first  and  second  sounds  of  the  heart  and  their 
variation  when  the  myocardium  is  involved  and  an  appreciation  of 
changes  in  cardiac  outline. 

While  the  presence  of  murmurs  should  indicate  heart  involvement 
(with  the  exception  perhaps  of  certain  murmurs  in  the  2nd  left  intercostal 
space)  they  need  not  necessarily  mean  endocarditis  or  valvular  change; 
for  a  goodly  per  cent,  of  them  disappear  and  are  probably  attributable 
to  hypersemia  of  the  valves  or  such  an  affection  of  the  myocardium  as 
entails  a  relative  insufficiency  of  the  valves.  The  statistics  of  some 
authors  (Kemp)  show  that  nearly  half  of  the  cases  with  cardiac  compli- 
cations clear  up  their  signs  before  leaving  the  hospital  and  that  no  mean 


ACUTE  RHEUMATIC  FEVER  55 

proportion  of  those  not  cleared  up  at  the  time  of  discharge  have  no  per- 
manent damage  to  the  valves. 

Aortic  valve  lesions  show  more  myocardial  involvement  than  the 
mitral  (Brooks). 

If  the  murmur  appears  early  in  the  disease,  it  is  more  likely  to  be 
the  expression  of  valvular  endocarditis  than  if  it  occurs  later,  at  which 
time  relative  insufficiency  from  loss  of  tone  may  well  obtain. 

Aortic  insufficiency,  double  valve  lesions,  and  pericarditis  increase 
the  gravity,  but  the  repetitions  of  the  cardiac  involvement  is  what 
constitutes  the  greatest  danger. 

When  all  active  manifestations  of  the  rheumatism  have  ceased 
and  the  patient  has  been  kept  in  bed  six  weeks  to  two  months  beyond 
this,  he  may  be  allowed  up  in  a  chair  and  then  on  his  feet,  but  always 
guided  by  the  cardiac  response;  for  a  pulse  rate  out  of  all  proportion  to 
the  effort  made  betokens  a  cardiac  irritability  that  gives  warning  of  the 
prematurity  of  the  effort. 

In  case  the  heart  decompensates,  it  is  to  be  treated  as  a  decompen- 
sated  heart  under  other  circumstances. 

The  gravity  of  these  cardiac  complications  has  been  accentuated  by 
the  studies  of  Dunn1  on  over  300  cases  of  cardiac  disease  of  rheumatic 
origin.  He  states  that  the  immediate  mortality  of  rheumatic  cardiac 
disease  is  about  20  per  cent,  and  that  the  final  mortality  of  the  affection 
followed  at  least  ten  years  is  60  per  cent.  The  mortality  is  seen  chiefly 
during  childhood.  After  young  adult  life  is  reached  it  falls  to  only  7  per 
cent.  Most  patients  who  weather  the  greater  dangers  of  childhood  and 
arrive  at  adult  life  get  on  remarkably  well  and  this  is  attributed  to  an 
adaptation  that  takes  place  between  the  patient  and  his  heart  during 
the  period  of  growth.  Moreover,  this  author  declares  the  earlier  the 
cardiac  lesion  is  acquired  the  more  likely  is  the  patient,  if  adult  life  is 
achieved,  to  lead  an  active  and  normal  existence. 

After-Treatment  of  cardiac  disease  in  children  has  been  well 
discussed  by  Dunn.1  It  is  largely  a  question  of  prophylaxis.  With  our 
present  conviction  that  the  tonsil  is  the  usual  portal  of  entry,  it  seems 
logical  to  remove  the  tonsil,  if  the  patient  has  been  the  subject  of  tonsil- 
litis or  if  the  tonsil  shows  evidence  of  disease. 

One  of  the  most  important  items  of  the  after  treatment  of  the  heart 
in  rheumatism  is  the  regulation  of  his  activities.  One  feels  that  he  is 
constantly  steering  between  the  Scylla  of  over-strain  and  the  Charybdis 
of  under-exercise. 

I  believe  Dunn  is  correct  in  concluding  that  the  danger  of  the  former 
is  less  than  the  latter.  I  heartily  favor  his  plan  of  regulated  exercise 
1  American  Journal  of  Diseases  of  Children,  August,  1913. 


56  TREATMENT  OF  ACUTE  INFECTIOUS  DISEASES 

beginning  soon  after  the  disappearance  of  symptoms.  At  first  with 
passive  movements  against  resistance,  and  later  active  exercise  always 
within  the  limits  of  the  heart's  demonstrated  capacity  to  cope  with  it. 
Overstepping  the  limits  is  shown  by  rapidity  of  heart  action  and  dyspnea. 
If  a  child  can  Resume  the  normal  activities  of  cnildhood  without  provok- 
ing these  symptoms,  he  should  be  allowed  to  pursue  them.  Coddling 
merely  because  heart  murmurs  are  heard  really  does  the  child  great  harm. 
Exposures  to  damp  cold  likely  to  provoke  recurrence  of  rheumatism  must 
be  avoided  or  a  removal  to  a  climate  where  rheumatism  is  less  prevalent 
is  advisable  when  it  is  feasible  to  carry  out  this  plan. 

Pulmonary  Complications.  Pneumonia  and  pleurisy  occur  in 
a  considerable  number  of  cases,  some  authors  giving  the  figures  as 
high  as  10  per  cent.  I,  myself,  have  seen  it  frequently  in  the  severe 
rheumatism,  and  always  with  cardiac  involvement.  The  figure  10  per 
cent,  represents  merely  the  incidence  in  the  rheuumatic  fever  in  general, 
but  in  cardiac  complications  and  especially  severe  cases,  they  are  much 
more  frequent  accompaniments.  Pleurisy  and  pneumonia  occur  rarely 
if  the  heart  is  not  affected.  When  the  heart  is  the  seat  of  endocardial 
changes  only,  the  incidence  is  probably  less  than  10  per  cent,  but  with 
pericarditis,  which  always  means  a  severe  infection,  pleurisy  or  pneu- 
monia or  both  probably  occur  in  half  of  the  cases  while  if  both  pericar- 
dium and  endocardium  are  involved  the  figures  rise  to  a  still  higher  point. 

Pericarditis,  pleurisies,  pneumonias,  like  subcutaneous  nodules,  are 
expressions  of  a  virulent  infection.  The  pleurisy  may  be  an  extension 
from  a  pericarditis,  but  this  is  by  no  means  the  necessary  origin  and 
probably  in  the  majority  of  instances  pleurisy  is  an  expression  of  direct 
infection.  Pneumonia  as  a  complication  is  more  frequent  than  pleurisy, 
though  they  often  occur  together  as  one  might  assume.  The  pleurisy  is 
usually  dry,  but  there  may  a  serous  exudate  sufficient  to  tap.  Both  the 
pleurisy  and  the  pneumonia  are  more  likely  to  be  on  the  left  side.  The 
pneumonia  is  very  often  a  gradual  development  and  the  signs  are  often 
atypical;  for  example,  a  fall  of  temperature  by  crisis  is  not  the  rule, 
the  physical  signs  may  clear  up  as  rapidly  as  they  appear;  the  cough  is 
not  characteristic  and  the  sputum  is  not  rusty.  My  own  experience  has 
been  that  the  physical  signs  are  those  of  a  lobar  pneumonia  with  a 
massive  pleural  exudate  and  it  has  seemed  to  me  that  it  does  not  so 
characteristically  involve  the  whole  lobe  as  a  primary  lobar  pneumonia. 

Sometimes  the  type  may  be  that  of  a  broncho-pneumonia.  Pulmon- 
ary edema  may  occur  and  at  times  infarctions.  Bronchitis  occasionally 
is  a  complication. 

The  treatment  of  these  conditions,  the  pleurisies,  pneumonias,  pul- 
monary edemas,  infarctions  and  bronchitis  is  such  as  would  be  instituted 


ACUTE  RHEUMATIC  FEVER  57 

under  other  circumstances,  and  does  not  call  for  an  intermission  of 
the  salicylates  (see  Pneumonia,  Chap.  IX;  Bronchitis,  Chap.  VII). 

Other  Complications.  Sore  throat,  if  severe  is  to  be  treated 
as  described  under  Scarlet  Fever  (see  Chap.  XVII  and  Tonsillitis 
Chap.V). 

The  mouth  throughout  the  illness  should  be  kept  scrupulously 
clean  (see  Pneumonia,  Chap.  IX). 

Other  complications  are  numerous  but  rare. 

The  skin  eruptions,  urticaria,  erythema  multiforme  or  nodosum, 
and  purpuras  require  no  special  treatment. 

Hemorrhages  from  the  nose,  stomach,  bowel,  kidney  may  occur 
but  rarely  demand  interference. 

Venous  thrombosis  is  a  rare  complication  and  is  treated  as 
under  other  circumstances.  Once  in  my  experience  an  embolism  of 
the  popliteal  artery  occurred  necessitating  amputation. 

Anaemia  is  a  striking  feature  of  the  disease,  and  indicates  in 
convalescence  the  use  of  iron  and  iron-containing  foods. 

Sweats  of  a  severe  type  have  long  been  associated  in  the  minds 
of  physicians  with  rheumatism,  and  may  require  especial  consideration. 
They  are  very  acid,  and  may  cause  considerable  irritation.  Sponging 
with  a  mild  alkaline  solution,  as  1  per  cent,  sodium  bicarbonate,  gives 
relief.  The  skin  should  be  kept  dry  with  one  of  the  numerous  powders 
that  contain  talcum,  or  one  made  of  equal  parts  of  zinc  oxide  and  starch. 
If  the  sweating  is  very  severe,  atropine  may  be  used  in  doses  of  1/100  to 
1/50  grain.  (0.0006-0.0015  Gm.) 

Vaccine  Therapy.  All  the  phenomena  of  acute  rheumatic  fever 
seen  to  me  to  demonstrate  that  it  is  an  infectious  process  and  yet,  in 
spite  of  the  careful  work  that  has  been  done  to  determine  the  organism 
concerned,  the  positive  findings  are  not  very  convincing.  Nevertheless 
it  seems  wise  to  me  to  continue  to  make  blood  cultures  during  the  febrile 
period  and  to  take  cultures  from  the  crypts  of  the  tonsils  either  in  situ 
or  after  enucleation;  from  teeth;  from  excised  subcutaneous  nodules; 
from  sinuses,  ears  or  other  obvious  foci  of  infection.  Joint  fluids  have 
been  repeatedly  cultured  but  are  almost  invariably  negative.  If  these 
cultures  are  positive,  most  particularly  those  from  the  blood  or  deep 
Crypts  of  excised  tonsils  and  obvious  contamination  can  be  excluded,  I 
am  accustomed  to  have  vaccines  made  from  them  and  by  their  adminis- 
tration give  the  patient  at  least  the  benefit  of  the  doubt  in  this  debatable 
question  of  the  specificity  of  the  organism.  It  must  be  remembered, 
more  particularly  in  adults,  but  by  no  means  in  them  exclusively,  that  a 
toxic  arthritis  derived  from  any  of  the  foci  mentioned  may  closely 
simulate  rheumatic  arthritis,  though  the  heart  is  very  rarely  involved. 


58  TREATMENT  OF  ACUTE  INFECTIOUS  DISEASES 

And  in  these  cases  vaccine  therapy  after  the  removal  of  the  focus  of  infec- 
tion, is  of  real  value.  I  am  accustomed  to  administer  these  vaccines 
when  the  case  has  gone  on  to  a  long  continued  infection  or  is  subacute 
in  its  manifestations  or  between  the  exacerbations  of  the  rheumatism. 
My  best  results  have  been  obtained  with  vaccines  cultured  from  the  deep 
crypts  of  the  excised  tonsils,  but  here  of  course,  the  enucleation  of  the 
tonsil  itself  is  probably  the  more  potent  factor  in  the  irnpiovement. 

The  Dosage.  The  first  dose  should  be  tentative.  I  begin  with 
5,000,000-10,000,000,  though  some  authors  prefer  so  low  a  dose  as  1,000,- 
000.  It  is  my  custom  to  give  the  dose  twice  a  week.  The  increase  in  dose 
depends  upon  the  reaction.  If  there  is  no  reaction  one  may  increase 
the  dose  to  10,000,000,  20,000,000,  40,000,000,  75,000,000,  125,000,000, 
200,000,000,  and  then  add  100,000,000,  or  more,  to  each  dose. 

If  there  is  a  slight  local  reaction  one  advances  more  cautiously;  if 
a  slight  general  reaction,  do  not  increase  the  next  dose;  if  a  marked 
general  reaction,  wait  for  two  or  three  days  after  it  has  subsided  and 
begin  again  with  a  lesser  dose. 

I  have  myself  provoked  an  unfortunate  exacerbation  of  symptoms 
with  too  large  a  beginning  dose  (in  this  case  50,000,000) . 

The  reaction  may  be  a  reddened  and  tender  area  at  the  site  of  in- 
jection or  a  recrudescence  of  local  lesions,  e.  g.,  in  joints  or  a  general 
reaction  of  fever,  accelerated  pulse  and  the  other  manifes tations 
of  slight  infection.  More  serious  consequences  can  follow  careless 
dosing. 

The  number  of  injections  is  a  matter  of  judgment  and  depends  on 
results.  I  prefer  eight  to  twelve  doses  and  sometimes  more. 

The  technique  is  that  of  any  hypodermic  injection,  a  clean  syringe 
and  needle  and  a  clean  site  of  injection. 

The  syringe  should  be  graduated  like  a  tuberculin  syringe  to  hun- 
dredths  of  a  c.c. 

When  the  heart  is  involved  one  should  be  even  more  careful  in  the 
dosage. 

Intravenous  Injections  of  Foreign  Protein  (Foreign  Protein 
Therapy),  Shock  Terapy.  The  use  of  non-specific  vaccine  or  for- 
eign protein  has  been  recently  agitated  in  the  treatment  of  acute  rheu- 
matic arthritis  as  well  as  in  other  acute  infectious  processes,  especially 
typhoid  fever.  Various  proteins  have  been  utilized,  both  from  certain 
foodstuffs  and  bacterial  bodies.  All  of  these,  regardless  of  their  origin, 
when  given  intravenously  produce  a  striking  reaction.  Indeed,  favorable 
results  from  the  use  of  such  foreign  proteins  seem  to  depend  on  these 
reactions.  Shortly  after  the  injection  there  is  a  chill,  accompanied  by  a 
leucopenia;  in  an  hour  or  two  a  febrile  reaction  which  lasts  about  2-3 


ACUTE  RHEUMATIC  FEVER  59 

hours  and  accompanying  this  a  sharp  rise  in  the  leucocyte  count,  which 
gradually  returns  to  normal  in  24  to  48  hours.  In  my  ward  at  Bellevue, 
typhoid  bacilli  or  sometimes,  and  especially  when  a  gonococcus  arthritis 
is  a  possibility  in  the  case,  the  bodies  of  killed  gonococci  are  used  as  the 
foreign  protein.  After  the  reaction,  in  favorable  cases,  there  is  a  fall  of 
temperature  and  a  striking  amelioration  of  symptoms;  that  is,  a  disap- 
pearance of  pain  and  a  diminution  of  the  swelling  in  the  joint.  Cecil, 
reporting  on  30  cases  in  our  ward  at  Bellevue  Hospital,  found  40  per 
cent,  were  relieved  of  their  symptoms  without  recourse  to  salicylates. 
In  the  rest  it  was  necessary  to  supplement  the  vaccine  treatment  with 
the  salicylates.  Unhappily,  nearly  all  these  cases  that  had  improved, 
relapsed  in  some  measure.  We  can  only  theorize  about  how  these 
beneficial  results  ensue,  but  it  seems  probable  that  these  injections  in 
some  way  distribute  antibodies,  sometimes  spoken  of  as  "a  mobiliza- 
tion." Moreover,  both  the  febrile  reaction  excited  and  the  leucocytosis 
that  follows  are  themselves  useful  instruments  in  combating  the  infec- 
tion. Our  dosage  has  been  25,000,000  typhoid  bacilli,  with  increasing 
doses  to  50,000,000,  75,000,000,  etc.,  at  intervals  of  a  day  or  two  after  the 
subsidence  of  the  preceding  reaction.  While  the  results  are  not  all  that 
might  be  desired  and  in  a  case  with  cardiac  complications  should  be 
undertaken  with  great  care,  nevertheless  it  is  a  measure  that  may  afford 
prompt  and  lasting  relief  in  a  sufficient  number  to  warrant  its  con- 
tinuance. 

CHOREA 

Chorea  is  often  looked  upon  and  treated  as  a  separate  and  distinct 
disease,  but  chorea  minor  or  Sydenham's  chorea,  long  appreciated  as 
mysteriously  connected  with  rheumatism  and  as  commonly  complicated 
by  the  same  kind  of  cardiac  disease  as  acute  rheumatism  is  now  pretty 
generally  looked  upon  as  but  one  manifestation  of  rheumatism. 

Treatment  then  of  chorea  minor  is  the  treatment  of  rheumatism 
except  that  rest  is  even  more  insisted  on  and  more  difficult  to  attain 
when  both  fever  and  pain  are  absent. 

Isolation  is  a  very  important  part  of  the  treatment.  This  is 
a  guarantee  of  freedom  from  excitement.  All  visitors  and  relations 
are  excluded  and  the  child  sees  only  the  mother  or  nurse.  How  absolute- 
this  shall  be,  how  long  continued  depends  on  the  progress  of  the  case 
and  the  temperament  of  the  patient. 

As  avoidance  of  excitement  as  well  as  physical  rest  is  the  desideratum, 
much  depends  on  the  temperament  of  the  mother  or  nurse.  This  does 
not  mean  that  the  patient  is  imprisoned  and  such  isolation  can  be  carried 


60  TREATMENT  OF  ACUTE  INFECTIOUS  DISEASES 

on  in  the  open  air  or  the  patient  sent  away  to  the  country  with  the  nurse 
and  isolation  effected  there.  In  acute  cases,  however,  the  darkened 
quiet  room  is  preferable. 

The  diet  should  be  sufficient  and  that  of  the  healthy  child  in  the 
milder  cases  arid  in  the  acuter  cases  sufficient  too,  but  chosen  as  in  the 
febrile  cases. 

These  measures  alone  are  often  sufficient.  They  should  be  persisted 
in  until  effectual  or  for  six  weeks  to  two  months  have  passed.  Of  course 
a  time  comes  when  the  need  of  light  and  air  makes  us  abandon  the  closer 
confinement,  or  the  child's  depression  may  forbid  its  continuance. 

Local  Measures.  Warm  baths,  especially  before  sleeping  are  often 
sedative  in  their  effects  and  sometimes  hot  packs  have  a  similar  result. 

In  febrile  cases  cool  sponges  may  be  of  value. 

Drugs.  As  a  rheumatic  manifestation  salicylates  are  indicated 
as  in  acute  rheumatism,  but  there  is  quite  a  widespread  belief  that 
of  the  salicylates  acetyl  salicylic  acid  (aspirin)  has  a  decided  superiority 
over  the  others.  The  dosage  should  be  that  specified  for  rheumatism. 

Time  honored,  too,  is  the  use  of  arsenic.  It  may  be  given  in  any 
form,  but  the  preparation  perhaps  to  be  preferred  is  the  liquor  potassii 
arsenitis  or  Fowler's  solution.  The  dose  begins  with  m.  ij  to  iij  (0.13- 
0.20  c.c.)  increasing  up  to  the  point  of  tolerance.  The  urine  is  carefully 
watched  meanwhile  and  with  any  evidence  of  albuminuria  the  drug  is 
promptly  stopped.  If  the  stomach  or  bowels  are  affected  or  there  is 
puffiness  under  the  eyes  we  stop  until  the  symptoms  disappear  and  begin 
again  on  half  the  dose. 

Vaccines.  I  have  had  but  a  limited  experience  with  the  use  of 
vaccines  in  chorea,  but  believe  there  is  a  field  for  them  in  chorea,  when 
administered  with  the  above  precautions. 

I  deplore  the  use  of  mixtures  of  organisms  of  unknown  value  and 
strength  so  widely  advertised  by  commercial  interests. 

Treatment  of  Symptoms.  Restlessness  may  sometimes  be  con- 
trolled by  the  use  of  luminal  in  half  grain  doses  (0.03  Gm.)  three  or 
four  times  a  day.  In  adults  slightly  larger  doses  may  be  used.  Three 
cases  in  my  practice  have  shown  diploplia  even  on  these  doses  which 
quickly  cleared  up  when  the  drug  was  omitted. 

When  the  patient  is  very  restless  and  the  movements  severe,  one 
•may  use  choral,  best  by  rectum,  in  doses  of  gr.  v-xxx  (0.30-2  Gm.) 
according  to  age,  remembering  that  children  bear  relatively  large  doses. 
Codeine  is  sometimes  very  effective  in  controlling  the  movements. 
Dosage  should  be  appropriate  to  age  and  it  is  to  be  remembered  that  it  is 
very  much  more  effective  when  given  hypodermically.  In  an  adult  the 
dose  ranges  from  1/8  to  1  grain  (0.008-0.06  Gm.)  of  the  phosphate. 


ACUTE  RHEUMATIC  FEVER  61 

For  the  worst  forms  and  the  maniacal  type  morphine  sulphate  in 
doses  of  gr.  1/16-1/4  (0.004-0.016  Gm.)  or  hyoscine  hydrobromide  gr. 
1/200-gr.  1/100  (0.0003-0.0006  Gm.)  may  be  necessary. 

At  times  the  patients  movements  are  so  violent  that  measures  have 
to  be  taken  to  restrict  them  lest  the  patient  throw  himself  from  the 
bed  and  suffer  injury.  In  the  hospital  side  boards  have  to  be  attached  to 
the  bed  and  lined  with  pads  or  pillows  to  prevent  trauma  following  the 
violent  motion.  In  children  the  same  precaution  should  be  taken  with 
the  crib.  I  have  seen  the  skin  on  the  bony  parts,  over  the  heels,  malleoli, 
elbows,  actually  cornified  from  the  constant  attrition.  One  is  likely  to 
get  sores  difficult  to  manage.  The  part  liable  to  damage  should  be 
padded. 

Auto-Sero-Therapy :  This  method  has  been  recently  advocated. 
Goodman  describes  his  method  as  follows:  Withdraw  50  c.c.  of  blood, 
centrifugalize,  pipette  off  serum  and  place  on  ice.  Do  a  lumbar  puncture 
and  withdraw  15-20  c.c.  of  fluid.  Heat  the  serum  to  body  temperature 
and  slowly  inject  (into  the  subarachnoid  space)  taking  10-15  minutes, 
15-18  c.c.  of  fluid.  In  a  series  of  30  cases  so  treated,  he  reported 
20  cases  cured  and  7  improved.  By  cure  he  defines  the  cessation 
of  all  twitching  in  a  week.  It  is  assumed  that  some  ferment  or 
antibody  present  in  the  serum  is  introduced  directly  to  the  site  of 
irritation. 

Convalescence  from  Rheumatism.  The  patient  should  be  kept 
in  bed  for  some  time  after  the  symptoms  have  subsided,  one  or  two 
weeks;  if  the  heart  has  been  involved,  longer,  as  detailed  above. 

The  diet  should  be  increased  to  include  green  vegetables,  later  eggs, 
fish,  and  meat  if  they  have  not  already  been  allowed.  It  should  be  simple 
in  its  character  and  in  the  manner  of  its  preparation.  It  should  be  suffi- 
cient, but  not  excessive,  nor  should  the  patient  be  teased  to  stuff  by 
palatable  dishes.  A  change  of  environment  often  helps  to  establish 
convalescence,  but  the  patient  should  not  be  hurried  away  too  soon  or 
exposed  to  discomforts  in  his  new  surroundings  for  the  mere  sake  of  the 
change. 

Prophylaxis.  The  avoidance  of  rheumatism,  so  lamentable  in 
its  consequences,  must  rest  upon  our  education  of  the  public  in  hygiene, 
through  the  schools  and  other  agencies.  The  gospel  of  fresh  air  must 
be  preached,  clean  bodies,  proper  clothing,  avoidance  of  neglect,  such  as 
remaining  in  wet  and  damp  clothing.  More  than  this,  parents  and 
teachers  must  be  made  to  understand  the  meaning  of  chorea,  sore 
throats,  stiff  necks,  and  "growing  pains"  in  children,  and  the  results 
of  neglect. 

The  physician  should  be  the  teacher,  as  the  term  " doctor"  implies, 


62  TREATMENT  OF  ACUTE  INFECTIOUS  DISEASES 

both  in  his  daily  walks  and  in  the  more  public  capacity  of  lecturer, 
health  officer,  school  inspector,  etc.  The  school  inspectorship  is  rife 
with  the  possibilities  of  infinite  good. 

The  upper  air  passages  afford  the  portal  of  entry  of  the  vast  majority  of 
rheumatic  infections. 

Tonsils  and  adenoids  hypertrophied  to  the  point  of  obstruction,  even 
though  they  have  never  been  the  seat  of  acute  infection  should  be  re- 
moved. 

Tonsils  and  adenoids  that  have  been  the  seat  of  infection  whether 
accompanied  or  followed  by  rheumatism  or  not  should  be  removed. 

Tonsils  and  adenoids  in  all  cases  of  rheumatism  should  be  removed 
between  the  attacks. 

There  is  a  difference  of  opinion  expressed  by  excellent  observers  as  to 
the  advisability  of  removing  tonsils  during  an  acute  attack  of  rheu- 
matic fever.  That  such  a  procedure  may  entail  additional  infection 
cannot  be  denied,  nor  does  it  seem  advisable  to  submit  a  patient  to  the 
other  exigencies  of  an  operative  procedure  during  the  height  of  an  infec- 
tion. Finally  foreign  body  pneumonia  is  an  all  too  frequent  sequel  of 
tonsillar  enucleation  even  in  health.  But  when  the  infection  is  persistent 
or  the  heart  involved  and  other  measures  fail  to  control  the  infectious 
process  it  becomes  a  question  as  to  whether  the  danger  of  leaving  a  focus 
of  infection  is  not  greater  than  the  dangers  entailed  in  its  removal. 
Hence  the  difference  of  opinion.  The  most  brilliant  result  I  have  ever 
seen  in  promptly  controlling  an  acute  rheumatic  fever  with  serious 
cardiac  involvement,  lasting  for  10  to  12  weeks,  followed  a  tonsillar 
enucleation,  which  was  done  at  a  time  when  an  acute  appendical  attack 
necessitated  an  operation  for  removal  of  that  organ. 

I  favor  complete  enucleation  of  the  tonsil.  The  tissue  should  be  care- 
fully preserved  in  a  sterile  container  to  be  submitted  to  bacteriological 
investigation  for  the  purpose  of  identification  and  preparation  of  vac- 
cines. 

Sinuses  should  be  examined  and  any  abnormality  of  the  nose  at- 
tended to. 

The  teeth,  especially  that  condition  known  as  pyorrhea  alveolaris 
contribute  to  infection,  though  in  my  experience  the  so-called  toxic 
arthritis  has  more  commonly  been  associated  with  this  infection  than 
the  clinically  true  rheumatism. 

These  should  have  dental  consideration  and  it  is  a  condition  that 
puts  to  the  test  the  best  dental  skill. 

Some  investigators  believe  that  bronchial  infection  and  intestinal 
infection  point  the  road  to  rheumatic  infection  and  certainly  these 
conditions  demand  attention. 


ACUTE  RHEUMATIC  FEVER  63 

Rheumatic  children,  especially,  when  showing  nervousness  should 
not  be  urged  at  school. 

Moon  has  sensibly  remarked  that  they  should  do  no  evening  work 
and  should  rest  in  the  middle  of  the  day. 

When  in  these  cases  headache  and  poor  sleep  intervene  or  there  is  a 
frank  exacerbation  of  nervousness  the  little  patient  should  be  taken 
out  of  school  until  matters  improve. 

Damp  cold  has  long  been  known  to  provoke  rheumatism  and  recur- 
rences of  rheumatism  and  Rosenow  declares  that  exposure  to  cold 
after  injection  of  rabbits  with  the  rheumatic  organism  increases  the 
percentage  and  degree  of  joint  involvement. 

This  of  course  accentuates  the  necessity  of  avoidance  of  exposure 
to  cold  and  wet;  the  importance  of  promptly  changing  wet  stockings 
and  clothes,  removal  from  cold  damp  houses  and  localities  and  the 
importance  of  warm  clothing,  and  especially  underclothing  containing 
wool. 

SUMMARY 
Rest. 

Quiet. 

Exclusion  of  visitors. 

Mental  rest. 

Freedom  from  annoyance,  conversation,  business  cares  in  the  adult, 

efforts  at  amusement  in  children. 
Good  nursing. 

Bed. 

Hospital  type  preferred.    Gatch  bed,  see  text. 

Woven  wire  spring. 

Finn  mattress. 

Flannel  blankets. 

Flannel  nightgown — open  down  front  or  side. 

Room. 

Light  and  air. 
Avoid  draughts. 
Temperature  65°  F.  to  70°  F. 
Open  air. 

Diet. 

Calories — approximate  3,000  in  adult  and  more  if  well  taken. 

Protein  65  to  75  Gm. 

During  early  hours  with  high  fever  and  anorexia  don't  push  food. 

Milk— 640  calories  to  1  quart.    Protein  33  Gm. 

Sugar — 120  calories  to  1  ounce. 

Cereals — about  100  calories  to  large  serving.    Average:  protein  4  Gm. 

Rice — about  100  calories  to  large  serving. 


64  TREATMENT  OF  ACUTE  INFECTIOUS  DISEASES 

Oatmeal  cooked — 100  calories  to  5.5  ounces.     Protein,  4.25  Gm. 

Oatmeal  dry — 1  oz.— 120  calories. 

Cream — 16%,  calories,  50  per  ounce.    Protein,   1  Gm. 

Cream — 40%,  calories,  120  per  ounce.    Protein,  1  Gm. 

Eggs — 70-89  calories,  each.    Protein,  7  Gm. 

Eggs — Yolk,  50-65  calories. 

Eggs,  Whites — 16-25  calories. 

Flours  in  general  approximate  100  calories  to  the  ounce.-    Protein, 

3Gm. 

Bread — 100  calories  to  thick  slice  (1  &  1/3  ounce).    Protein,  4  Gm. 
Butter — 100  calories  to  pat  ^scant  J£  ounce) .   230  calories  to  the  ounce. 
Milk,  soups,  mutton  broths,  chicken  broths  thickened  with  rice  or 

cereals. 

Fish6          '  I as  temPerature  approaches  normal. 
Meats  after  temperature  has  been  normal  a  few  days. 

Bowels. 

Salts— Epsom,  Rochelle,  Glauber's  gss.-j  (15-30  Gm.)  followed  by 

enema  of  plain  water  or  soapsuds  if  needed. 
LATEK. 
Enemata. 
Salines. 

Hunyadi  water— other  mild  equivalents  on  the  market,  liquor 
magnesii  citratis,  gviii-xii  (240-360  c.c.),  Seidlitz  powders  or,  if 
obstinate,  salts  mentioned  above  and  enemata  to  follow. 

"  Specific  "  Treatment. 

Sodium  salicylate  gr.  xx  (1.33  Gm.)  every  two  hours.  As  pain  sub- 
sides cut  gradually  to  gr.  xv,  then  gr.  x  (1.00-0.66  Gm.)  every 
two  hours. 

Keep  at  gr.  x  (0.66  Gm.)  until  all  active  phases  have  past. 

After  symptoms  have  disappeared  gr.  x  or  v  (0.66-0.33  Gm.)  every 
two  or  three  hours  for  a  week  or  ten  days. 

Then  for  four  to  six  weeks  give  gr.  x  or  v  (0.66  or  0.33  Gm.)  three 
or  four  times  a  day.  Continue  with  alkali  (see  below) . 

If  satisfactory  results  do  not  ensue  increase  dose  to  production  of 
toxic  manifestations.  This  may  be  anticipated  in  the  adult  in  the 
neighborhood  of  150  to  200  grains  a  day,  depending  on  the  sex, 
weight,  etc. 

Administer  alkali;  citrate  of  potash,  acetate  of  potash,  bicarbonate  of 
soda,  enough  to  render  urine  alkaline  and  keep  it  alkaline  or  neutral. 

Rule — two  grains  of  the  alkali,  preferably  bicarbonate,  for  one  of 
the  salicylate. 

Toxic  manifestations.     (See  text.) 

3 

SodiiSalicylatis 5ss.  •      (15) 

Aqua?,  q.  s.  ad f  §ii  (60) 

M. 

S.  Teaspoonful  in  water  every  two  hours. 


ACUTE  RHEUMATIC  FEVER  65 


Acidi  Salicylic!  .................................  3iv         (15) 

Sodii  Bicarbonatis  ..............................  5iii         Q2) 

Aquae,  q.  s.  ad  .................................  f  §ii         (60) 

M. 

S.  Teaspoonful  in  water  every  two  hours. 
V 

Acidi  Acetylsalicylici  ...........................  gr.  cl        (10) 

Ft  cap.  no.  xxx. 

S.  Three  (3)  or  four  (4)  every  two  hours. 

Give  alkaline  as  above,  but  between  the  doses,  to  avoid  incompatibil- 
ity, or  push  dose  to  toxic  manifestations.  This  may  be  anticipated 
in  the  adult  near  120  or  160  grains  a  day  depending  on  sex  (weight). 

Toxic  manifestations  (see  text). 

Methyl  salicylate  or  oil  of  gaultheria  in  m.  xv-xx  (1.00-1.30  c.c.) 
every  two  hours. 

I* 

Olei  Gaultheriae  ..............................  f3v 

Ft.  cap.  no.  xxx. 

S.  Two  (2)  every  two  hours. 
S 

Olei  Gaultherise  ..............................  f  3iv          (15) 

Acaciae,  q.  s. 

Aquae,  q.  s.  ad  ................................  f  gii  (60) 

M.  ft.  emul. 

S.    Teaspoonful  every  two  hours. 
3 

Olei  Gaultherise  ...............................  f  5iv          (15) 

Acaciae.  .  .  .  ...................................  q.  s. 

Potassii  Citratis  ...............................    5i  (30) 

Aquae,  q.  s.  ad  ................................  f  giv        (120) 

M.  ft.  emul. 

S.    Teaspoonful  every  two  hours. 

Give  bicarbonate  or  other  alkali  gr.  ii  to  m.  i  of  the  oil;  may  push  to 

production  of  toxic  manifestations. 

These  may  be  looked  for  at  about  120  minims  (8  c.c.)  a  day. 
For  toxic  manifestations.     (See  text.) 
Diplosal  —  (salicylsalicylic  acid)  gr.  x  (0.66  Gm.)  every  two  hours. 

9 

Diplosal  ......................................  20.00          5v 

Divide  in  capsules  no.  xxx. 
S.    One  every  two  hours. 

Or  push  to  toxic  manifestations,  which  may  be  anticipated  as  dose 
approximates  80  to  100  grains  a  day  depending  on  sex  (weight). 

Administer  alkali  between  doses.  Dose  about  gr.  iv  (0.25  Gm.)  per 
grain  diplosal. 

Toxic  manifestations.     (See  text.) 


66  TREATMENT  OF  ACUTE  INFECTIOUS  DISEASES 

Rectal  administration  of  salicylates. 

Use  a  thin  starch  paste  at  body  temperature,  5iv-vj  (120-180  c.c.). 

Add  }/%  daily  dose  of  salicylate,  e.  g.,  5i  (4  Gm.). 

Add  m.  i  to  ii  of  tincture  of  opium  if  needed  to  retain. 

Inject  slowly;  hold  buttocks  together  for  a 'few  minutes. 

Dose  every  twelve  hours. 

or 

Give  whole  dose,  e.  g.,  5ii  (8.00  Gm.)  in  the  same  amount  of  starch 

paste  once  a  day. 
Alkalis,  e.  g.,  bicarbonate  of  soda,  is  given  at  two-hour  intervals  by 

the  mouth,  the  total  day's  dose  to  amount  to  two  grains  to  one  of 

the  salicylates. 

Intravenous  administration. 

Technique.     (See  text.) 

Use  when  salicylates  cannot  be  borne  for  any  reason  as  in  the  case 
of  idiosyncrasies. 

Drugs  to  relieve  pain. 
Acetanilid,  gr.  iss.  (0.10  Gm.)  every  J/£  hour  for  4  doses;  repeat  at  six 

or  eight  hour  intervals,  or  gr.  ii-iii  (0.15-0.20  Gm.)  every  two 

hours.    Give  in  capsules  or  powders. 
Acetphenetidin  (Phenacetin),  gr.  iii  to  v  (0.20-0.30  Gm.)  every  two 

hours.    Give  in  capsules  or  powders. 
Antipyrin — gr.  iii-iv  (0.20  Gm.)  every  two  hours.    Give  in  capsules  or 

solution. 
For  severe  pain. 

Morphine  sulphate  best  hypodermically,  gr.  1/16-gr.  to  1/8  (0.004- 
0.008)  adult  dose. 

Symptomatic  treatment. 

Joints. 

Rest. 

Semi-flexion. 

Pillows,  cushions,  sand  bags. 

Carefully  padded  splints. 

Cold. 

Ice  bag  or  ice  coil. 

Cold  compresses. 
Use  of  Gatch  bed. 
Fomentations. 

Protection  with  non-absorbent  cotton  and  flannel  bandages. 
Drugs. 

Methyl  Salicylate  or  oil  of  wintergreen. 

3 

Methyl  Salicylatis. 

Menthol aa  15  per  cent. 

Petrolati  q.  s.  ad 30.00        gi. 

M.  et  fiat  unguentum. 
S.    Local  use. 


ACUTE  RHEUMATIC  FEVER  67 

Ichthyol. 

U 

Ichthyolis 25  per  cent. 

Petrolati  q.  s.  ad 30.00        5i 

M.  et  fiat  unguentum. 
S.    Local  use, 

Counterirritation. 
Cautery. 
Fly-blister. 
Pressure. 
Flannel  bandage. 
Rubber  bandage. 

Persistent  effusions. 

Paracentesis — For  Technique,  see  text. 
LATER  MEASURES. 

Gentle  manipulation. 

Massage. 

Fomentations. 

Baking. 

Vaccines. 

Complications. 
Hyperpyrexia. 
Cold  baths. 
Put  in  tub  at  65°  F.,  or  to  save  shock  at  80°  F.,  cooling  it  to 

65°  F.,  gradually. 

Keep  temperature  of  water  down  by  adding  ice. 
Take  patient  out  when  temperature  is  102°  F. 
Repeat  when  patient's  temperature  rises  to  104°  F.  or  105°  F. 
Cold  packs. 

Sheet  wrung  out  of  cold  water  and  wrapped  about  patient's 
body  and  then  rubbed  with  pieces  of  ice. 

Cardiac  complications. 

Continue  salicylates  in  full  dose  as  described  above. 

Continue  in  bed  two  months  at  least,  after  all  other  signs  of  rheu- 
matism have  disappeared,  and  as  much  longer  as  the  condition  of 
the  heart  may  seem  to  warrant. 

Allow  first  to  sit  up,  then  to  get  on  feet,  but  always  guided  by  evi- 
dences of  heart's  stability. 

Increased  rate  and  tumultuousness  of  beat  out  of  proportion  to 
effort  made,  indicates  continuance  of  rest. 

If  heart  decompensates  it  is  to  be  treated  like  a  decompensated  heart 
under  other  circumstances. 

The  acute  febrile  process  does  not  centra-indicate  the  use  of  digitalis 
in  full  doses. 

Digitalis,  full  dose  the  equivalent  of  gr.  ix-xii  (0.60-0.80  Gm.)  daily 


68  TREATMENT  OF  ACUTE  INFECTIOUS  DISEASES 

for  three  or  four  days  or  until  signs  of  accumulation  or  desired 
results  ensue,  then  stop  two  or  three  days  and  resume  with  smaller 
dose  gr.  iii  (0.20  Gm.)  a  day  (adult  dose). 

After  treatment. 
Tonsilectomy. 
Avoidance  of  damp  cold. 
Change  of  climate. 

Regulated  exercise  beginning  soon  after  disappearance  of  symptoms. 
Passive  first,  then  active  within  limit  of  demonstrated  cardiac  capacity. 

Pneumonia  and  pleurisy. 
Treat  as  under  other  circumstances. 
Continue  salicylates  in  full  doses. 

Sore  throat. 

Careful  oral  toilet.  (See  Pneumonia,  Chap.  IX.)  Tonsillitis,  Chap.  V. 
When  severe  treat  as  in  Scarlet  Fever.  (See  Chap.  XVI.) 

Insomnia. 
Trional,  gr.  x-xx  (0.66-1.33  Gm.)  in  early  evening  and  repeat  if  needed 

two  or  three  hours  later  (adult  dose). 
Give  in  capsule  or  powder. 
Chloralamid,  gr.  xx-xxx  (1.33-2.  Gm.)  in  early  evening;  repeat,  if 

needed,  in  two  to  three  hours  (adult  dose). 
When  pain  is   present  use  morphine  hypodermically  gr.   1/16  to 

gr.  %  (0.004-0.015  Gm.)  (adult  dose). 

Anaemia. 

Iron.  Blaud's  pill  (Pil.  ferri  carbonatis),  or  Vallet's  Mass  (Massa 
ferri  carbonatis)  gr.  v-x  (0.33-0.66  Gm.)  three  times  a  day. 

In  children  lesser  doses  of  same,  or  bitter  wine  of  iron  (Vinum  ferri 
armarum)  5i-iii  (4-12  c.c.),  three  times  a  day. 

Sweats. 

Sponging  with  1  per  cent,  bicarbonate  of  soda. 
Talcum  powder. 

Zinc  oxide  and  starch  equal  parts.    Apply  locally. 
Atropine  sulphate  gr.     1/100  to  1/50  (0.0006-0.0013  Gm.). 

Vaccine  therapy. 

Use  only  autogenous  vaccines. 
Seek  organisms  by  cultures. 

1.  from  blood. 

2.  from  joint  fluid. 

3.  from  subcutaneous  nodules. 

4.  from  depths  of  tonsilar  crypts. 

5.  from  sites  of  obvious  infection  as  teeth,  ears,  sinuses. 
Time  to  use  vaccines. 

During  subacute  stage  or  between  exacerbations. 


ACUTE  RHEUMATIC  FEVER  69 

Dosage. 

1st  dose  tentative,  5,000,000-10,000,000. 
In  cardiac  case  1,000,000-5,000,000. 
Frequency. 

Twice  a  week. 
Succeeding  doses. 

In  the  absence  of  reactions,  double  the  doses  up  to  150,000,000- 

200,000,000  then  increase  by  100,000,000  at  a  dose. 
Reaction.    (See  text.) 

If  reaction  is  slight  and  local  do  not  increase  next  dose. 

If  reaction  is  severe  and  general  wait  until  all  signs  of  reaction 

have  subsided  for  two  or  three  days  and  begin  with  lesser  dose. 
Number  of  doses. 

Depends  on  results  and  is  a  matter  of  judgment,  10  to  12  or  perhaps 

more. 
Technique — that  of  any  hypodermic  medication;  cleanliness  of 

instruments,  operator  and  site  of  operation. 
Syringe  graduated  to  fractions  of  a  c.c.,  e.  g.,  tuberculin  syringe. 
In  cardiac  cases. 
Beginning  dosage  lower. 
Advance  in  dosage  more  cautiously. 
Foreign  Protein  Therapy.     (See  Text.) 
Tonsillectomy.     (See  Text.) 

Chorea. 

Rest  in  bed. 
Isolation. 

Diet.    Liberal  if  afebrile;  as  in  rheumatism  if  febrile  (see  above). 
Local  measures. 
Warm  baths  especially  before  sleeping,  or  two  or  three  times  a 

day.    Hot  packs  once  a  day.    Cool  sponges  in  febrile  cases. 
Drugs. 
Salicylates  in  full  doses  as  in  rheumatism. 

Acetyl  salicylic  acid  (Aspirin)  the  form  preferred. 
Arsenic;  any  form. 
Fowler's  Solution  (Liq.  potassium  arsenitis),  m.  ii-iii  (0.12^0.20 

c.c.),  as  a  beginning  dose,  increase  a  minim  a  day  or  a  minim  a 

dose  a  day  up  to  the  point  of  tolerance;  that  is,  disturbance  of 

stomach  or  bowels  or  puffiness  under  the  eyes. 
Watch  urine  for  albumin. 
Then  stop  until  symptoms  disappear;  begin  with  }/%  largest  dose 

and  increase  again. 
Vaccines. 

As  in  rheumatism,  but  with  less  dose  and  cautious  increase. 

Autoserotherapy. 

(See  text.) 
Marked  restlessness  and  violent  movements. 

Chloral,  gr.  v-gr.  xxx  (0.33-2.00  Gm.)  in  gi-iiii  (60-90  c.c.)  of 
warm  milk  by  rectum  at  night.  (Children  take  large  doses 
relative  to  their  age.) 


70  TREATMENT  OF  ACUTE  INFECTIOUS  DISEASES 

Most  severe  and  maniacal  cases. 

Morphine  sulphate,  gr.  1/16  to  gr.  J^  (0.004-0.015). 

Hyoscine  hydrobromide,  gr.  1/200  to  gr.  I/ 100  (0.0003-0.0006  Gm.). 

Convalescence  in  rheumatism. 

In  bed  one  or  two  weeks  after  symptoms  subside. 

In  cardiac  cases  longer,  as  above. 

Diet.    Made  more  liberal.    Change  of  environment  to  be  considered. 

Prophylaxis. 

Education  of  public. 
Fresh  air. 
Cleanliness. 
Warm  clothing. 
Avoidance  of  chilling. 
Inspection  of  upper  air  passages. 
Elimination  of  tonsils  and  adenoids. 
Teeth  to  be  attended  to. 

Avoidance  of  excitement  and  urging  in  school  of  the  nervous  children 
already  infected. 

After  treatment  of  the  heart. 
See  text. 


CHAPTER  IV 

ACUTE  RHINITIS— CORYZA 

THIS  affection,  known  to  the  laity  as  a  "cold  in  the  head/'  is  one  of  the 
most  infectious  diseases  to  which  we  are  exposed  and,  as  immunity 
seems  but  short-lived,  these  two  facts  contribute  to  make  it  the  most 
common  of  our  afflictions. 

What  the  etiological  agent  is,  is  not  known.  Pathogenic  organisms 
in  abundance  have  been  recovered  from  the  secretions  of  the  nasal 
passages  during  an  acute  rhinitis,  but  no  one  of  these  has  been  proven  to 
be  the  etiological  agent.  A  strong  plea  has  been  made  for  a  filterable 
virus,  and  such  it  may  well  prove  to  be;  but  it  remains  for  the  future  to 
definitely  settle  that  question.  Moreover,  it  is  possible  that  the  rhinitis 
that  accompanies  or  ushers  in  certain  other  acute  infections,  such  as 
measles  or  influenza,  may  be  actuated  by  other  organisms  than  those 
responsible  for  a  primary  attack. 

The  common  cause  for  an  infection  is  direct  exposure  to  an  individual 
suffering  an  attack.  Some  men  are  inclined  to  think  that  that  is  the  only 
mode  of  infection.  Others  believe  that  many  are  in  a  carrier  state, 
harboring  the  inf ecting  organism  as  most  of  us  do  Type  IV  pneumococcus 
and  afford  opportunity  for  infection  by  lowering  resistance  as  is  the  case 
with  Type  IV  pneumococcus.  Such  a  lowering  of  resistance  follows 
exposure  and  chilling,  such  as  wet  feet  and  wet  clothes,  remaining  in 
draughts  when  the  skin  is  warm  and  moist  and  it  has  seemed  to  me  that 
conditions  causing  intense  congestion  of  the  tissues  of  the  nasal  mucous 
membrane,  like  uncontrolled  sneezing,  open  portals  to  infection.  Nasal 
obstruction,  adenoids  or  possibly  old  sinus  infections,  may  predispose  to 
attacks. 

Symptomatology — The  symptoms  are  local  and  in  the  severe 
forms,  general.  They  are  so  familiar  to  every  reader  that  an  attempt  to 
picture  them  is  an  act  of  supererogation.  The  stuffed  nose,  especially 
following  nasal  obstruction,  the  thin  watery  secretion  that  wets  handker- 
chief after  handkerchief,  and  excoriates  the  nasal  openings,  the  dull 
frontal  headache,  and  in  severe  cases,  the  conjunctival  congestion,  the 
miserable  malaise,  or  even  general  aches  and  pains,  with  perhaps  a  slight 
fever,  constitute  the  catalogue  of  events. 

The  seriousness  of  an  attack  lies  in  the  fact  that  it  weakens  the  bar- 


72  TREATMENT  OF  ACUTE  INFECTIOUS  DISEASES 

riers  of  resistance  to  other  infections  that  invade  the  rest  of  the  air 
passages  and  contiguous  structures. 

Treatment  —  Early  or  abortive.  The  object  of  this  is  to  pro- 
mote hyperemia  and  a  leucocytosis,  two  reactions  of  protective  signifi- 
cance. To  be  effectual  the  treatment  must  be  prompt  and  in  the  early 
hours  of  the  attack. 

A  hot  bath  or  a  hot  mustard  foot-bath  (for  technique,  see  index) 
is  taken;  after  which  the  patient  should  go  to  bed.  The  bed  must  be 
warm  and  the  patient  should  get  between  blankets  or  put  on  a  flannel 
night  dress  or  pajamas.  A  hot  water  bottle  should  be  placed  at  the  feet 
and  hot  drinks  should  be  taken  —  hot  lemonade  with  or  without  a  dash  of 
whisky,  (5ss.-15  c.c.)  or  hot  weak  tea  or  hot  Imperial  drink  (a  table- 
spoonful  of  cream  of  tartar  in  two  pints  of  boiling  water  —  it  is  poorly  sol- 
uble in  cold  water  —  to  which  is  added  lemon  juice  or  lemon  peel  and 
sugar  to  the  taste)  .  All  this  induces  sweating,  diaphoresis,  and  for  the 
same  purpose  Dover's  powder  (Pulv.  ipecac  et  opii)  has  long  been  a 
favorite  drug  of  many.  It  may  be  given  to  an  adult  in  the  full  dose  of 
gr.  x  (0.66  Gm.)  or  in  any  fractions  of  this  dose  at  frequent  intervals  un- 
til the  whole  amount  is  taken. 

Great  care  must  be  taken  when  perspiring  freely  to  avoid  exposure; 
so  the  treatment  should  not  be  undertaken  except  in  warm  rooms  and  a 
warm  and  properly  prepared  bed. 

Aches  and  pain  are  best  treated  with  acetylsalicylic  acid  (aspirin) 
in  doses  of  gr.  v-gr.  x  (0.33-0.66  Gm.)  at  2  or  3  hour  intervals 
or  small  doses  of  a  coal-tar  preparation  at  frequent  intervals;  e.  g.,  ace- 
tanilid  gr.  i  ss.  (0.10  Gm.),  antipyrin  gr.  ii  (0.120  Gm.),  acetphenetidin 
gr.  iii  (0.20  Gm.)  at  hourly  intervals  for  4  doses,  then  every  2  hours 
in  such  a  prescription  as  follows: 


Acetanilidi  .............................  1  .  50        (gr.  xx  iiss.) 

Sodii  Bicarbonatis  ............  ..........  1  .  00        (gr.  xv) 

Caffeinae  Citratse  .......................  0.50        (gr.  viiss.) 

M.  et  div.  in  cap.  no.  xv. 

S.  One  every  hour  for  4  doses,  then  every  2  hours. 


or: 


Codeinae  Sulphatis 0. 125        (gr.  ii) 

Acetphenetidini  (phenacetin) 3 . 00          (gr.  xlv) 

Acidi  acetylsalicylici  (aspirin) 5 . 00          (gr.  Ixxv) 

M.  et  div.  in  cap.  no.  xv. 
S.  One  every  2  or  3  hours. 


ACUTE  RHINITIS—  CORYZA  73 

When  the  secretion  is  excessive,  if  the  physician  does  not  prescribe, 
the  patient  is  pretty  sure  to  take  one  of  the  multitudinous  rhinitis  or 
coryza  tablets  on  the  market,  the  bases  of  which  are  belladonna,  cam- 
phor, aconite,  and  often  quinine  and  small  doses  of  opium. 

Local  Treatment.  The  object  of  this  is  to  promote  drainage 
and  ventilation  and  so  afford  comfort.  It  is  effected  by  applications 
made  directly  to  the  sites  involved,  by  sprays  or  by  inhalations. 

Direct  Applications.  It  is  well  to  precede  all  applications  by 
a  cleansing  spray  of  normal  salt  solution,  Setter's  tablets,  or  one  of  the 
many  alkaline  solutions  on  the  market  which  contain  solutions  of  both 
alkaline  salts  and  certain  volatile  oils.  Argyrol  15  per  cent,  to  25  per 
cent,  applied  on  a  cotton  swab  on  an  applicator,  or  used  as  a  spray  seems 
at  present  to  be  the  choice  for  the  purpose.  In  addition  to  this  it  is  by 
some  clinicians  dropped  in  the  conjunctival  sacs,  thus  gaining  access  to 
the  nasal  mucous  membrane  by  way  of  the  lachrymal  ducts. 

Drops  of  adrenalin  (epinephrin)  1-1000  into  either  nostril,  or  used 
as  a  spray  or  applied  on  a  pledget  of  cotton  on  an  applicator  and  left  in 
contact  with  the  mucous  membrane  for  a  few  seconds,  astringe  these 
structures  and  allow  of  ventilation.  Cocaine  has  been  used  for  the 
same  purpose;  but  there  are  too  many  objections  to  it  to  permit  of  rec- 
ommendation; 1  per  cent,  solution  of  the  hydrochloride  is  that  com- 
monly used.  Antipyrin,  3  per  cent,  solution,  is  used  for  the  same  purpose 
and  is  less  objectionable  than  the  cocaine;  at  times  the  two  are  combined 
in  the  strengths  specified. 

The  constringency  induced  by  the  above  applications  is  maintained 
by  ointments  or  sprays  the  essential  ingredient  of  which  is  menthol. 

Ointments.  —  As  useful  will  be  found  the  following: 


Aristol  ....................................  1  .00  (gr.  xv) 

Mentholis  .................................  0.  10  (gr.  iss.) 

Petrolati  q.  s.  ad  ..........................  15.00  (gss.) 

M.  S.    Local  use. 


or: 


Mentholis 0.20  (gr.  iii) 

Olei  Pini  Pumilionis 0. 125  (m.  ii) 

Olei  Rosae 0.060  (m.  i) 

Petrolati 30.00  (gi) 

M.  S.    Local  use. 

Sprays.     One  may  use  1  per  cent,  each  of  menthol,  camphor  and 
oil  of  eucalyptus  hi  Benzoinol  or  liquid  petrolatum. 


74  TREATMENT  OF  ACUTE  INFECTIOUS  DISEASES 

or: 

$ 

"Mentholis gr.  xxx  (2.0   Gm.) 

Camphorse gr.  xx  (1.30  Gm.) 

Eucalyp'tolis m.  xx  (1.30  c.c.) 

Olei  Rosse m.  iii  (0.20  c.c.) 

Benzoinol  q.  s.  ad gii  (60.00  c.c.) 

M.  S.    Use  in  oil  atomizer."  (Coakley.) 

If  this  is  found  too  strong  the  menthol  may  be  reduced  to  gr.  x-xv 
(0.66-1.  Gm.)  or  the  whole  diluted  with  more  benzoinol  to  an  agree- 
able strength. 

Special  oil  atomizers  must  be  used  for  all  these. 

Inhalations.  Simple  steam  inhalations  may  be  found  grateful,  or 
compound  tincture  of  benzoin,  or  the  oil  of  pine,  one  or  two  teaspoonfuls 
on  the  hot  water  of  the  inhaler,  or  a  few  drops  of  the  alcoholic  saturated 
solution  of  menthol  in  the  same  manner,  or  such  prescription  as  follows : 

I* 

Olei  Pini  Sylvestris 5ss.          (2.00  c.c.) 

Olei  Eucalypt gss.        (15.00  c.c.) 

Mentholis gr.  x         (0.66  Gm.) 

Creosoti m.  x         (0. 66  c.c.) 

Tr.  Benzoin  Comp.  q.  s.  ad gii          (60.00  c.c.) 

M.  S.  20  drops  in  boiling  water  for  inhalation.  For  these  inha- 
lations one  may  use  pitchers,  carafes,  kettles,  with  stiff  paper 
rolled  for  a  funnel,  or  a  croup  kettle,  or  one  of  the  simple  and  in- 
expensive inhalers  on  the  market. 

Later,  when  the  discharge  becomes  thickened,  warm  alkaline 
sprays  may  be  used  such  as  follows : 

3 

"Sodii  Bicarbonatis 

Sodii  Biboratis aa  gr.  xxxii        (2  Gm.) 

Aquae  dest.  q.  s.  ad 5  iv  (120  c.  c.) 

M.  S.    Use  as  spray."  (Coakley.) 

or  one  of  the  mild  alkaline  "antiseptics"  of  the  trade.  If  there  is  still 
much  obstruction  to  the  nasal  passages,  adrenalin  (epinephrin)  or  anti- 
pyrin  as  directed  above.  Such  a  spray  as  follows  may  prove  of  value  : 

V 

Iodine 0.06     (gr.  i) 

Menthol 0. 10     (gr.  i  ss.) 

Liquid  petrolatum 60.00      (gii) 

M.  S.    Spray  from  oil  atomizer  with  hard  rubber  parts. 

Nasal  irrigations  and  douches  are  deplored  as  being  likely  to  induce 
otitis. 


ACUTE  RHINITIS— CORYZA  75 

Sore  Throat.  If  a  sore  throat  accompanies  the  coryza,  the  spec- 
ified inhalations  may  be  used.  If  a  tonsillitis,  see  Chap.  V.  If  a  cough 
without  definite  signs  in  chest,  one  may  assume  a  tracheitis  and  give 
such  a  mixture  as  follows : 

3 

"Codeinae  Sulphatis gr.  iii  (0.20  Gm.) 

Ammonii  Chloridi 5i  (4.00  Gm.) 

Thiocol 5ii  (8.00  Gm.) 

M.  et  ft.  cap.  no.  xxiv. 

S.  One  every  2  hours."  (Bingham.) 

For  detailed  treatment,  see  Tracheitis,  Chap.  VII. 

Complications.  As  has  been  said  the  respiratory  tree  at  large 
may  be  involved  or  the  contiguous  structures.  See  Bronchitis,  Pneu- 
monia, Laryngitis,  Tonsillitis  (Chap.  VII,  IX,  VI,  V). 

Sinusitis.  This  is  a  not  uncommon  complication.  The  frontals, 
ethmoids,  or  sphenoid  sinuses,  or  antra  of  Highmore  may  become  in- 
volved. The  methods  detailed  above  of  local  applications  to  facilitate 
ventilation  and  drainage  are  of  considerable  prophylactic  value;  but 
clear  evidences  of  sinus  involvement  requires  expert  attention.  To  those 
who  must  rely  on  their  own  management,  special  treatises  on  this  subject 
are  recommended. 

Antral  Involvement.  Efforts  at  drainage  should  first  be  made 
before  having  recourse  to  radical  procedure.  See  details  under  Grip, 
Chap.  XI.  For  lavage  and  surgical  procedure  consult  special  treatises. 

Otitis.  This  is  always  to  be  feared,  especially  in  young  children. 
Irrigations  and  douches  should  not  be  used  in  the  nose.  Instructions 
should  be  given  to  blow  nose  gently,  one  side  at  a  time,  to  avoid  forcing 
infection  into  Eustachian  tubes  and  antra  or  sinuses.  When  antra  are 
involved  try  to  suck  discharges  back  into  pharynx,  to  expel  by  mouth 
rather  than  blow  nose. 

Prophylaxis.  Rooms  should  be  kept  at  68°  to  70°  and  as  in 
most  steam  heated  apartments  the  air  is  deprived  of  its  moisture  an 
effort  should  be  made  to  replace  this  by  suitable  devices. 

Removal  of  obstructions — such  as  tonsils,  adenoids,  and  the 
rest  of  infected  tissue  of  Waldeyer's  ring;  attention  to  hypertrophied 
turbinates,  deviated  septa,  and  chronically  infected  sinuses  and  antra. 

Personal  Hygiene.  Training  the  vaso-motor  supply  of  superficial 
vessels,  so  that  the  vessels  will  quickly  respond  to  changes  in  en- 
vironment. This  is  done  by  daily  cold  baths,  sleeping  in  well-ventilated 
rooms,  windows  open  at  all  times  of  year,  exercise  in  the  open  air,  avoid- 
ance of  overclothing,  especially  about  the  neck. 


76  TREATMENT  OF  ACUTE  INFECTIOUS  DISEASES 

Dress  lightly  in  house,  and  on  going  out  add  clothing  suitable  to 
the  weather. 

Underclothing  should  be  of  silk  or  cotton  mesh  or  if  it  contains  wool 
should  be  very  light. 

SUMMARY 
Treatment. 

Early  or  abortive. 
Must  be  begun  early. 
Hot  bath. 
Hot  mustard  foot  bath. 

For  technique  see  Pneumonia,  Chap.  IX. 
Patient  must  go  to  bed  promptly. 
Bed  to  be  made  up  with  blankets  rather  than  sheets  or  patient  to 

wear  flannel  night  clothes. 
Hot  water  bottle  at  feet. 
Hot  drinks  to  be  taken. 

Lemonade  with  whisky,  gss.  (15  c.c.). 

Imperial  drink  (one  tablespoon  of  cream  of  tartar  in  one  quart 
of  boiling  water,  and  sugar  to  taste). 

Dover's  powder  gr.  x  (0.66  Gm.)  or  in  small  fractions  at  frequent 
intervals  until  this  amount  is  taken. 

Avoid  exposure  if  this  treatment  is  taken. 

Aches  and  pains. 
Acetylsalicylic  acid  (aspirin)  gr.  v-gr.  x  (0.33-0.66  Gm.)  every  two 

or  three  hours. 
Or  coal-tar  preparations,  acetanilid  gr.  iss.  (0.10  Gm.),  antipyrin,  gr. 

ii  (0.120  Gm.),  acetphenetidin  (phenacetin)  gr.  iii  (0.20  Gm.). 
Give  any  one  of  these  at  hourly  intervals  for  4  dosss  and  then  every 

2  hours. 
or: 


Acetanilidi  ...........................  1  .  50         (gr.  xxiiss.) 

Sodii  Bicarbonatis  ....................  1  .  00         (gr.  xv) 

Caffeinse  Citratse  .....................  0  .  50         (gr.  viiss.) 

M.  et  div.  in  cap.  no.  xv 
S.    One  every  hour  for  four  doses  and  then  one  every  two  hours. 

or: 


Codeinse  Sulphatis  .........................  0.  125         (gr.  ii) 

Acetphenetidini  (Phenacetin)  ................  2  .  50          (gr.  xl) 

Acidi  Acetylsalicylici  (Aspirin)  ..............  5.0  (gr.  Ixxv) 

M.  et  div.  in  cap.  no.  xv. 

S.  One  every  two  or  three  hours. 

For  excessive  secretions  combinations  of  belladona,  aconite,  quinine, 


ACUTE  RHINITIS—  CORYZA  77 

opium,  in  one  of  the  multitudinous  formulas  offered  by  pharma- 
ceutical houses  may  be  tried. 

Local  applications. 

Precede  by  cleansing  sprays  of  normal  saline  or  one  of  the  alkaline 

solutions  on  the  market. 
Argyrol  15%-25%  on  swab  of  applicator  or  as  spray.    Same  may  be 

dropped  in  conjunctival  sacs. 
To  relieve  obstruction. 
Adrenalin  (epinephrin). 

1  :1000  dropped  in  either  nostril  or  sprayed  or  applied  by  appli- 
cator and  left  in  contact  with  mucous  membrane  for  a  few 
seconds. 

Or  antipyrin,  3%  solution. 

The  effects  of  the  above  may  be  continued  by  sprays  or  oint- 
ments with  menthol  as  the  chief  ingredient. 

3 

Aristol  .....................................   1.0  (gr.  xv) 

Mentholis  ..................................   0  .  10          (gr.  iss.) 

Petrolati  q.  s.  ad  ..........................  15.00          (gss.) 

M. 

S.  Local  use. 

or: 
9 

Mentholis  ..........................  .........  0.20  (gr.  iii) 

Olei  Pini  Pumilionis  ...........................  0.  125  (m.  ii) 

Olei  Rosse  ...................................  0.060  (m.  i) 

Petrolati  ....................................  30.00  (gi) 

M. 

S.   Local  use. 

As  sprays  one  may  use  1%  each  of  menthol,  camphor,  and  oil  of 
eucalyptus  in  benzoinol  or  liquid  petrolatum. 

or: 


"  Mentholis  ...............................  gr.  xxx  (2  Gm.) 

Camphorae  .............  •  .................  gr.  xx  (1.3  Gm.) 

Eucalytolis  ..............................  m.  xx  (1.3  c.c.) 

Olei  Rosse  ...............................  m.  iii  (0.2  c.c.) 

Benzoinol  q.  s.  ad  ........................  5ii  (60  c.c.) 

M. 

S.  Use  in  oil  atomizer."  (Coakley.) 

If  this  is  too  strong  reduce  the  menthol  to  gr.  x-xv  (0.66-1  Gm.)  or 
dilute  with  benzoinol. 

Inhalations. 
Simple  steam. 
Compound  tincture  of  benzoin. 


78  TREATMENT  OF  ACUTE  INFECTIOUS  DISEASES 

Oil  of  pine. 

One  or  two  teaspoonfuls  of  either  on  the  hot  water  of  inhaler  or 
one  or  two  drops  of  saturated  alcoholic  solution  of  menthol  in 
the  same  manner. 

or: 

3 

Olei  Pini  Sylvestris 3ss.  (2.00  c.c.) 

Olei  Eucalyti gss.  (15.00  c.c.) 

Mentholis gr.  x  (0.66  Gm.) 

Tr  of  Benzoin  Co.  q.  s.  ad. gii  (60.00  c.c.) 

M.  S.  20  drops  in  boiling  water  for  inhalation. 

For  inhalers  use  pitchers,  kettles  with  stiff  paper  rolled,  or  one  of  the 
simple  inhalers  on  the  market. 

Later  treatment. 
Warm  alkaline  sprays,  e.  g. 

$ 

Sodii  Bicarbonatis 

Sodii  Biboratis Sa  gr.  xxxii  (2.0  Gm.) 

Aquae  q.  s.  ad 5  iv  (120  c.c.) 

M. 

S.  Use  as  spray.  (Coakley.) 

May  use  mild  alkaline  antiseptics  of  the  trade. 

For  obstruction  of  the  nasal  passages  use  adrenalin  or  antipyrin  as 

above, 
or: 

3 

Iodine 0.06        (gr.  i) 

Menthol 0.10        (gr.  iss.) 

Liquid  Petrolatum 60.00         (gii) 

M. 

S.  Spray  from  oil  atomizer  with  hard  rubber  parts. 

Do  not  use  nasal  irrigations  and  douches  lest  they  induce  otitis. 
Sore  throat. 

Inhalations  as  above.    See  Tonsillitis  (Chap.  V). 
Cough. 

With  no  signs  in  the  chest,  probably  tracheitis. 

3 

Codeinse  Sulphatis gr.  iii         (0.20  Gm.) 

Ammonii  Chloridi 3i  (4.00  Gm.) 

Thiocol 5ii  (8.00  Gm.) 

M.  et  ft.  cap.  no.  xxiv. 

Or  see  Tracheitis,  Chap.  VII. 
Complications. 

Laryngitis.    (See  Chap.  VI.) 
Tonsillitis.      (See  Chap.  V.) 


ACUTE  RHINITIS— CORYZA  79 

.  Bronchitis.    (See  Chap.  VII.) 
Pneumonia.  (See  Chap.  IX.) 
Sinusitis. 

Local  applications. 

Persistent  cases  or  suspected  empyema,  see  special  treatises. 
Antrum  Involvement. 

Effect  drainage.     See  Influenza,  Chap.  XII. 
Otitis. 

Always  suspect  in  young  children. 

Routine  examination  of  ear. 

Avoid  douches. 

Blow  nose  gently  and  one  side  at  a  time. 

Suck  discharge  back  into  the  pharynx  rather  than  blow  nose. 

Prophylaxis. 

Temperature  of  rooms  68°  F.  to  70°  F. 

Replace  moisture  in  air  by  one  of  the  suitable  devices  on  the  market. 
Removal  of  obstructions — such  as  tonsils,  adenoids,  and  hypertro- 

phied  turbinates. 
Treat  chronically  infected  sinuses  and  antra. 

Personal  hygiene. 

Train  the  vasomotor  supply  of  the  superficial  vessels  by  cold  baths, 
sleeping  in  well  ventilated  rooms,  exercise  in  open  air,  avoid  over- 
dressing in  the  house  and  on  going  out  add  clothing  suitable  to  the 
weather. 

Underclothing  should  be  of  silk  or  cotton  mesh  or  if  it  contains 
wool  it  should  be  very  light. 


CHAPTER  V 

TONSILLITIS  AND  VINCENT'S  ANGINA 
TONSILLITIS 

BETWEEN  the  mouth  and  the  larynx  stands  the  wall  of  adenoid  tissue, 
designed  as  a  barrier  against  infection.  This  is  distributed  in  a  circle 
about  the  tube  and  is  known  as  Waldeyer's  ring.  It  accumulates  in 
masses  on  either  side  known  as  the  faucial  tonsils;  above,  where  it  is 
commonly  spoken  of  as  the  adenoid  or  adenoids,  its  structure  usually 
showing  a  central  and  lateral  lobes;  and  below,  where  it  is  known  as  the 
lingual  tonsil.  Lymphatics  from  the  mouth  drain  into  these  structures 
whose  function  it  is  to  check  infection  coming  from  these  sites.  Infec- 
tions which  force  these  barriers  pass  to  the  lymphatic  channels  and 
glands  beyond.  Their  importance  to  the  welfare  of  the  body  is  readily 
understood;  but  when  from  repeated  infections  they  become  the  sites  of 
chronic  infection,  harboring  organisms  ready  to  take  advantage  of  any 
lowering  of  the  individual's  resistance  they  become  a  menace  to  the 
integrity  of  many  remote  organs  and  all  too  frequently  to  life.  It  is 
generally  appreciated  that  the  tonsils  harbor  such  infection,  but  it  is  too 
commonly  forgotten,  especially  in  the  adult,  that  the  adenoid,  and  still 
more  the  lingual  tonsil  may  be  chronically  infected  to  continue  the  infec- 
tion, after  complete  enucleation  of  the  faucial  tonsils. 

However,  because  the  faucial  tonsils  are  most  commonly  and  most 
obviously  affected  we  speak  of  this  "sore  throat"  as  Tonsillitis. 

The  infecting  organisms  are  in  the  majority  of  instances  streptococcus 
hemolyticus,  but  the  invaders  may  be  streptococcus  non-hemolyticus, 
(viridans)  Staphylococcus  aureus  or  micrococcus  catarrhalis. 

The  structure  of  the  tonsil  with  its  deep  crypts,  which  one  may  think 
of  as  the  prints  of  fingers  thrust  deeply  into  dough,  favors  the  reception 
and  retention  of  pathogenic  bacteria. 

The  tonsils  become  swollen  and  reddened  and  bulge  out  from  between 
the  pillars  of  the  fauces,  the  peritonsillar  tissue  is  also  infiltrated  and 
reddened.  The  sites  of  the  plugged  crypts  appear  as  white  spots,  and 
afford  the  designation  of  follicular  tonsillitis.  Often  the  exudation  from 
adjacent  follicles  coalesce.  The  tissue  between  these  white  areas  is  red 
and  swollen. 

The  differential  diagnosis  from  a  diphtheritic  throat  is  often  very 


TONSILLITIS  AND  VINCENT'S  ANGINA  81 

difficult  and  many  times  can  be  made  only  by  cultures  and  micro- 
scopical examination  of  smears. 

The  characteristics  of  a  typical  tonsillitis  are  an  exudate  of  a  yellowish 
color  separated  by  a  deep  red  mucous  membrane  giving  a  patchy  appear- 
ance and  confined  to  the  tonsils.  It  may  be  removed  without  causing 
any  bleeding. 

The  sore  throat  of  diphtheria,  on  the  other  hand,  has  a  membrane 
of  an  ashen  gray  color.  It  usually  starts  at  one  point  and  spreads  out 
over  the  tonsil  and  may  extend  onto  the  pillars  of  the  fauces,  the  edge  of 
the  soft  palate  and  uvula.  It  is  firmly  adherent  and  when  removed 
leaves  a  bleeding  surface. 

The  worst  form  of  streptococcus  hemolyticus  infections  are  called 
septic  sore  throat  and  are  commonly  seen  in  milk-borne  epidemic 
mastitis  in  cows. 

The  cervical  glands,  receiving  the  lymphatics  draining  the  tonsils, 
become  enlarged  and  tender  and  in  severe  infections  may  break  down 
into  abscesses,  which  may  point  and  discharge  on  the  surface. 

Bullowa  insists  that  the  gland  which  receives  the  drainage  from 
the  tonsil  is  situated  high  up  in  the  triangle  made  by  the  sterno-cleido 
mastoid  and  the  posterior  belly  of  the  digastric  muscle  and  not  the  one 
at  the  angle  of  the  lower  jaw  commonly  called  the  tonsillar  gland. 

It  must  be  remembered  that  a  tonsillitis  may  be  the  expression  of 
rheumatism,  a  diphtheria,  an  early  symptom  of  scarlet  fever,  a  Vincent's 
angina,  or  the  precursor  of  an  infection  of  the  respiratory  tree  and  that 
syphilitic  sore  throat,  either  the  primary  lesion  or  secondary,  and  acute 
lymphatic  leukaemia  may  lead  to  an  error  of  diagnosis. 

Symptomatology.  The  onset  is  often  abrupt  and  the  evidences 
of  infection  severe.  Chilly  sensations  or  a  chill  followed  by  fever,  head- 
ache, general  muscular  pains  like  a  grip  infection  and  sore  throat  con- 
stitute the  symptomatology.  The  tonsils  are  swollen  and  red  and  the 
crypts  may  be  plugged  or  a  membrane  be  present. 

To  be  sure,  many  attacks  are  much  lighter  and  patients  may  insist 
on  keeping  about.  But  acute  tonsillitis  is  never  a  trivial  affair  and  the 
involvement  of  remote  structures,  such  as  the  kidney  or  the  heart  or 
joints  may  occur  in  what  seems  like  a  mild  attack. 

Treatment.  The  patient  should  be  confined  to  bed  even  in  a 
light  attack.  Children  and  all  the  members  of  the  family  who  are 
susceptible  to  sore  throats,  or  infection  of  the  air  passages  of  any  kind 
should  be  kept  away  from  the  patient.  In  fact,  there  is  little  common 
sense  in  allowing  any  person  to  come  into  contact  with  a  patient  suffering 
from  an  infectious  process  unless  it  is  to  act  in  the  capacity  of  a  nurse. 

Cultures  and  Precautionary  Measures.     Text-book  descriptions 


82  TREATMENT  OF  ACUTE  INFECTIOUS  DISEASES 

of  the  differential  diagnosis  between  follicular  tonsillitis  and  diphtheria 
lead  you  to  wonder  how  a  mistake  could  ever  be  made  or  to  marvel  that 
a  differentiation  can  ever  be  achieved. 

Experientia  docet  and  the  man  who  has  seen  much  of  these  two  con- 
ditions rarely  errs;  but  for  the  general  run  of  us  the  knowledge  that  a  net 
is  always  laid  for  the  unwary  and  that  a  text-book  follicular  tonsillitis 
may  be  diphtheritic,  plead  for  the  culture  tube  in  the  physician's  bag 
and  the  use  of  it  as  a  routine  in  dealing  with  sore  throats.  On  the  other 
hand  the  throat  highly  suspicious  of  diphtheria  may  turn  out  on  culture 
to  be  streptococcal  in  origin;  for  this  reason,  if  cultures  cannot  be  taken, 
or  reports  are  likely  to  be  delayed,  or  in  children  or  adults  showing 
prostration,  let  the  patient  have  benefit  of  the  doubt  and  administer 
antitoxin  at  once.  (See  Diphtheria,  Chap.  XVIII.) 

Diet  should  be  light.  The  condition  of  the  throat  causes  so 
much  pain  on  swallowing  that  all  articles  of  food  must  necessarily  be 
fluid,  or  at  the  most  semi-solid;  milk,  broths,  cereals,  custards,  jellies, 
ice-cream,  milk  toast  are  the  basis  of  such  a  dietary  and  one  may  be 
referred  to  the  diet  lists  given  in  the  chapters  on  Typhoid  Fever  and 
Pneumonia  for  the  several  items.  It  is  amazing  how  much  flesh  is 
lost  during  the  short  attack  of  tonsillitis  of  three  to  six  days  and  theoreti- 
cally a  dietary  should  take  these  needs  into  consideration;  but  when 
swallowing  is  torture,  knowing  it  to  be  an  affection  of  relatively  short 
course,  one  must  be  satisfied  with  what  the  patient  can  take  without 
great  discomfort.  Sometimes  the  food  is  preferred  hot,  sometimes  cold, 
sometimes  as  fluid,  again  with  a  little  consistency  and  the  frequency  must 
be  dictated  by  individual  considerations. 

Drink.  Water,  alkaline  water  and  such  fruit  juices  as  the  in- 
flamed structures  accept  without  discomfort  are  indicated  in  such  quan- 
tities as  the  patient  can  readily  take. 

Bowels.  At  the  beginning  of  the  illness  it  is  well  to  move  the 
bowels  with  a  mild  saline,  such  as  Hunyadi  water  or  one  of  its  many 
equivalents  on  the  market.  This  may  be  preceded,  if  one  so  chooses,  by 
a  smaU  dose  of  calomel  gr.  1/10-1/4  (0.006-0.015  Gm.)  at  10  or  15 
minute  intervals  until  one  grain  is  taken.  Liquor  magnesii  citratis  5  viii 
(240  c.c.),  a  Seidlitz  powder,  or  one  of  the  more  drastic  salts,  Epsom, 
Rochelle,  Glauber's  or  Sodium  Phosphate  in  §ss,  (15  Gm.)  doses  may 
be  preferred.  Throughout  the  illness  the  bowels  may  be  regulated  with 
enemata,  liquid  petrolatum,  cascara,  aloin,  phenolphthalein  or  a  mild 
saline  water. 

Drugs.  The  salicylates  have  always  been  favorites  in  the  treat- 
ment of  tonsillitis;  in  fact  perhaps,  because  as  a  local  manifestation  of 
rheumatism  it  seems  to  yield  to  this  so-called  specific  and  in  part  be- 


TONSILLITIS  AND  VINCENT'S  ANGINA  83 

cause  of  the  general  anodyne  effects  of  the  group.  It  may  be  given  as 
sodium  salicylate,  acetylsalicylic  acid  (aspirin),  salicin,  diplosal  or 
other  form,  my  choice  being  one  of  the  first  two.  The  usual  dose  is 
gr.  v-x  (0.33-0.66  Gm.)  at  two-hour  intervals  or  it  may  be  used  as  in 
rheumatism.  (For  details  and  prescriptions  see  Acute  Rheumatic  Fever, 
Chap.  III).  A  favorite  prescription  of  mine  combines  small  doses 
of  tincture  of  aconite  with  salicylate 

Tincturse    Aconiti 1.00        (m.  xvi) 

Sodii  Salicylatis 5.00        (gr.  Ixxx) 

Aquas  destillatse,  q.  s.  ad 60.00         (gii) 

M. 

S.    One  teaspoonful  every  two  hours.    (Delafield.) 

In  the  early  hours  of  the  infection,  the  so-called  sthenic  period,  coal- 
tar  preparations  may  be  used  for  the  general  aches  and  pains.  Acetan- 
ilid,  antipyrin,  acetphenetidin  (phenacetin)  alone  or  combined  with 
bicarbonate  of  soda  to  lessen  their  irritating  effects  on  the  stomach  and 
for  its  antidotal  action  or  with  citrated  caffeine  which  increases  the 
anodyne  action  and  is  assumed  to  counteract  the  depressing  action  of 
the  coal-tar  drugs  on  the  circulation,  an  assumption  which  is  more 
than  dubious. 

I  prefer  to  give  doses  smaller  than  the  usual  text-book  doses,  but 
at  frequent  intervals,  e.  g. 

Acetanilidi 1 . 50        (gr.  xxiiss) 

Sodii  Bicarbonatis 1 . 00         (gr.  xv) 

Caffeinse  Citratee 0.50         (gr.  viiss.) 

M.  et  div.  in  cap.  no.  xv. 
S.   As  directed. 

I  order  one  of  these  given  every  1/2  hour  for  four  doses,  then  every 
hour  for  four  doses,  then  every  two  hours.  (Adult  dose.) 

Fever.  This  is  usually  not  so  high  as  to  need  interference.  The 
drugs  above  mentioned  ameliorate  it,  though  not  given  for  that  partic- 
ular purpose.  If  the  fever  gives  the  patient  discomfort,  it  is  to  be  met  by 
cool  or  cold  sponges  of  water;  following  which  an  alcohol  rub  is  found 
gratifying. 

Care  of  the  Body.  A  daily  sponge  with  castile  soap  and  warm 
water  should  be  given.  The  nose  should  be  freed  from  secretions  by  the 
use  of  cotton  swabs  on  wooden  tooth-picks  as  applicators,  moistened  with 
a  saturated  solution  of  boric  acid  (4  per  cent.)  or  J^  to  J^  strength 
DobelTs  solution.  The  mouth  should  be  cleansed  by  rinsing  and  gargling 
with  the  same  solutions  and  food  removed  from  the  interstices  of  the 


84  TREATMENT  OF  ACUTE  INFECTIOUS  DISEASES 

teeth  and  from  between  the  gums  and  the  cheeks  and  lips  by  the  use  of 
cotton  swabs  on  wooden  applicators. 

Insomnia.  It  cannot  be  too  often  insisted  that  sleep  is  rest 
and  rest  is  repair.  As  a  rule  the  milder  hypnotics  are  sufficient ;  bromides 
gr.  xv  (1  Gm.),  trional  gr.  x-xv  (0.33-1  Gm.),  adalin  gr.  v  (0.33 
Gm.),  chloralamid  gr.  xx  (1.33  Gm.),  or  somewhat  more  potent  prep- 
arations; barbital  (veronal)  gr.  v-vii  ss.  (0.33-0.5  Gm.)  or  barbital 
sodium  (medinal)  in  the  same  doses.  If  the  pain  in  the  throat  is  keep- 
ing the  patient  awake  codeine  phosphate  gr.  J^  (0.015  Gm.)  or  mor- 
phine sulphate  gr.  1/8  (0.008  Gm.)  hypodermically  is  indicated. 

Local  Treatment.  It  not  infrequently  happens  that  an  appli- 
cation of  a  strong  solution  of  silver  nitrate  to  the  tonsils,  if  done  in  the 
first  few  hours  will  abort  or  decidedly  ameliorate  the  process.  This 
solution  should  be  25  per  cent,  to  50  per  cent,  and  applied  liberally  with 
a  swab.  Others  use  a  weaker  solution  of  silver  nitrate  40  to  60  grains 
(2.33  to  4  Gm.)  to  5i  (30  c.c.)  and  make  the  application  three  times 
a  day. 

I  advise  the  stronger  solution  in  the  first  12  hours  and  after  that  rely 
on  hot  irrigations  of  normal  saline  or  boric  acid  2  per  cent,  to  4  per  cent, 
at  100°  F.  to  115°  F.  and  if  the  throat  is  very  red  115°  F.  to  118°  F.,  every 
hour  or  two  while  awake.  For  efficiency  much  depends  on  technique.  I 
refer  the  reader  to  the  section  on  angina  under  Scarlet  Fever,  Chap. 
XVII  where  the  treatment  by  irrigations,  inhalations,  sprays  and  gargles 
as  well  as  external  applications  is  taken  up  in  detail. 

I  would  add  as  an  excellent  gargle,  though  my  faith  in  gargles  alone 
is  small,  one  made  up  as  follows:— 

9. 

Sodii  Salicylatis 
Sodii  Bicarbonatis 

Sodii  Biboratis aa  30        (51) 

One  teasponful  in  %  glass  of  hot  water  to  gargle.    (Goodridge.) 

Phenol  1-100  solution  used  as  a  gargle  is  said  to  relieve  pain.      (Hare.) 

If  properly  applied  the  throat  compress  is  of  practical  value  where 
there  is  much  pain.  The  technique  is  given  by  Baruch  as  follows: 

"  Although  this  compress  is  probably  more  frequently  applied  than 
the  other,  it  is  remarkable  how  little  its  rationale  is  understood  and  how 
imperfectly  it  is  applied.  The  usual  method  is  to  fold  a  handkerchief  or 
napkin  into  a  narrow  bandage,  dip  it  in  cold  water,  wring  it  out,  and  wind 
it  around  the  neck,  securing  it  by  pin.  In  a  very  short  time  the  move- 
ments of  the  patient  displace  the  bandage,  which  has  been  applied 
loosely  to  prevent  choking,  so  that  it  loses  its  shape,  allowing  air  to 
enter  freely  from  above;  more  or  less  chilling  is  then  produced  and  the 


TONSILLITIS  AND  VINCENT'S  ANGINA  85 

compress  dries  rapidly.  As  will  be  seen  in  the  description  of  the  thera- 
peutic indication  of  the  throat  compress,  the  object  is  defeated  by  this 
imperfect  application,  unless  it  is  intended  to  treat  some  tracheal  or 
laryngeal  trouble.  When  intended  for  the  treatment  of  tonsillitis,  diph- 
theria and  other  pharyngeal  affections,  the  throat  compress  should  be 
applied  as  follows:  A  piece  of  old  thin  linen,  of  sufficient  length  to  reach 
from  below  the  ear  on  one  side  to  the  same  point  on  the  left,  is  folded  into 
a  bandage  of  four  layers.  A  piece  of  flannel,  eight  by  twenty-four  inches, 
provided  with  a  slit  for  each  ear,  is  also  made  ready.  These  bandages 
are  fitted  by  actual  measurement  to  the  patient's  head,  so  that  they  may 
pass  under  the  chin  from  ear  to  ear.  The  linen  compress  bandage  is  now 
wrung  out  of  water  at  (60°  F)  and  laid  upon  the  middle  of  the  dry  flannel 
bandage.  While  the  wet  bandage  is  placed  under  the  chin,  the  flannel 
bandage  is  unrolled  from  the  top  of  the  head  and  passed  over  the  right 
side  of  the  head  (the  right  ear  being  made  to  protrude  through  the  slit) 
and  then  passed  under  the  chin  to  the  left  side,  where  the  left  ear  is  also 
allowed  to  protrude  (the  slit  being  made  longer  than  actually  needed,  to 
insure  perfect  apposition  of  the  bandage  and  prevent  pressure  on  the  ear). 
The  entire  bandage  is  now  drawn  firmly  over  the  head  and  secured  by 
pins.  Two  sets  of  bandages  are  required — one  being  allowed  to  dry 
while  the  other  is  in  use. 

"  In  children  and  restless  patients,  additional  security  is  afforded  by  a 
circular  turn  around  the  head  forming  a  bandage  to  which  the  throat 
compress  may  be  pinned."  Baruch.  "Hydrotherapy." 

Adenitis.     (See  Scarlet  Fever,  Chap.  XVII.) 

Nephritis.     (See  Scarlet  Fever.) 

Convalescence.    (See  Scarlet  Fever.) 

Tonsillectomy.    (See  Scarlet  Fever.) 

Septic  Sore  Throat.  The  virulent  forms  of  streptococcus  hemo- 
lyticus  infection  that  have  received  this  designation  are  associated  with 
such  degrees  of  toxemia  that  they  require  special  consideration.  With 
these,  too,  the  more  serious  complications  are  likely  to  ensue. 

Circulation.  Precisely  the  same  problem  is  presented  here  as 
in  Scarlet  Fever  (unless  endocarditis  has  intervened,  for  which  see 
below).  The  reader  is  referred  to  the  treatment  of  failing  circulation  in 
that  disease.  (Chap.  XVII.) 

Furthermore  a  daily  examination  of  the  heart  even  well  into  convales- 
cence should  be  made  and  frequent  examination  of  the  urine  and  es- 
pecially in  convalescence.  This  is  the  time,  too,  when  the  productive 
nephritis,  secondary  to  a  scarlet  fever,  the  rash  of  which  may  have  been 
overlooked  is  likely  to  develop. 

Toxemia.    Beside  the  supportive  treatment  one  has  to  consider 


86  TREATMENT  OF  ACUTE  INFECTIOUS  DISEASES 

the  value  of  the  specific  measures  we  have  at  hand.  This  question,  too, 
is  discussed  under  Scarlet  Fever.  (Chap.  XVII.) 

We  are  dealing  with  a  streptococcus  hemolyticus  and  may  have  re- 
course to  three  efforts  of  doubtful  value,  but  with  certain  theoretical 
justifications  behind  them,  e.  g.,  the  administration  of  polyvalent  strep- 
tococcus serum,  the  use  of  autogenous  or  polyvalent  vaccines,  and  trans- 
fusions. Details  of  these  procedures  will  be  found  under  the  chap- 
ters specified. 

Complications  and  Sequellse.  As  has  been  said  a  given  case 
of  tonsilitis  may  usher  in  a  rheumatic  infection  and  be  followed  by  a 
rheumatic  arthritis,  endocarditis,  chorea  or  other  manifestations.  On 
the  other  hand  an  infectious  arthritis  may  occur  and  an  acute  malignant 
endocarditis  or  if  the  infecting  organism  is  streptococcus  non-hemolyt- 
icus  (viridans)  a  subacute  bacterial  endocarditis. 

Nephritis.  An  acute  exudative  or  an  acute  productive  nephritis  may 
occur,  which  latter  may  pass  over  to  a  chronic  form.  This  is  to  be 
treated  as  under  other  circumstances.  (See  Scarlet  Fever,  Chap.  XVII.) 

Septicaemia  is  not  a  rare  result  of  a  septic  sore  throat.  This 
subject  is  considered  in  Chap.  XLV. 

Complications  due  to  the  involvement  of  more  contiguous  structures 
are: 

Otitis  media.  In  young  children  in  whom  this  process  may  occur 
without  pain,  a  routine  examination  of  the  ear  should  be  made.  Early 
incision  of  the  drum  is  indicated.  The  treatment  is  fully  considered 
under  Scarlet  Fever.  (Chap.  XVII.) 

Adenitis.  This,  too,  will  be  found  fully  discussed  under  Scarlet 
Fever. 

Peritonsillar  Abscess.  The  local  signs  and  symptoms  are  aggra- 
vated. The  pain  is  intense  and  may  extend  upward  to  the  ear  if  the  pus 
burrows  in  that  direction.  The  mouth  is  opened  with  difficulty,  swal- 
lowing is  painful  and  feeding  almost  impossible  so  that  with  the  toxemia 
and  loss  of  food,  weakness  and  loss  of  flesh  are  very  marked.  The 
anterior  pillars  of  the  fauces  are  red  or  purple  and  swollen  and  the  soft 
palate  often  involved.  There  is  a  bulging  of  the  tissues  concerned  frer 
quently  to  the  midline.  The  uvula  may  be  swollen  and  reddened. 

The  incision  is  made  in  the  most  prominent  portion  of  the  swelling. 
The  soft  palate  and  other  tissues  may  be  treated  by  application  of  10 
per  cent,  cocaine  hydrochloride  solution,  but  this  unhappily  does  not  do 
much  to  lessen  the  pain  of  incision.  A  sharp-pointed  curved  bistoury 
may  be  used,  the  blade  being  protected  with  adhesive  plaster  to  within 
a  half  inch  of  the  point.  The  incision  is  made  from  above  downward  and 
should  be  nearly  vertical  to  avoid  injuring  important  blood  vessels.  It 


TONSILLITIS  AND  VINCENT'S  ANGINA  87 

begins  at  a  point  above  the  soft  palate  where  it  joins  the  uvula  and  3/8 
of  an  inch  outside  of  the  inner  margin  of  the  anterior  pillar  of  the  fauces. 

The  incision  should  be  deep  to  the  extent  of  the  exposed  portion  of 
the  blade. 

Pus  should  follow  the  incision  but  it  is  possible  that  the  failure  to 
evacuate  pus  is  due  to  an  unsuccessful  incision  or  to  the  fact  that  a  pus 
pocket  has  not  yet  formed.  A  failure  to  make  a  successful  incision  is 
often  due  to  the  patient's  drawing  back  to  avoid  the  pain  and  there- 
fore the  head  should  be  firmly  supported  to  prevent  this. 

If  there  is  much  offensive  pus  Coakley  advises  syringing  or  sponging 
the  cavity  with  1:5000  phenol  (carbolic  acid)  and  inserts  a  strip  of 
iodofonn  gauze  to  prevent  too  rapid  closure.  If  no  pus  follows  the 
incision  it  may  appear  a  day  or  two  later.  Relief  will  be  afforded  by  a 
lessened  congestion  following  incision. 

If  pus  burrows  downward  in  the  posterior  pillar,  an  incision  is  made 
over  the  point  of  greatest  bulging. 

Convalescence.  Both  physician  and  patient  err  in  hastening  the 
period  of  convalescence.  Even  after  short  attacks  the  patient  plainly 
shows  the  effects  for  a  long  time.  In  the  World  War,  Army  surgeons 
studying  return  to  fitness  of  patients  after  tonsillitis,  found  the  period 
prolonged  to  an  extent  that  amazed  the  civilian  practitioner  and  made 
him  realize  the  injustice  he  has  regularly  done  his  patients.  Fresh  air, 
good  food  a  simple  tonic  of  strychnine  sulphate  gi.  1/60-1/30  (0.001- 
0.002  Gm.)  three  times  a  day  or  such  a  prescription  as  follows  may  be 
ordered: 

I* 

Tr.  Nucis  Vomicae  .........................  .....  20        (5v) 

Sodii    Glycerophosphatis  ........................  20        (5v) 

Aq.,  dest.  q.  s.  ad  ........................  ...  120        (5iv) 

M. 

S.  One  teaspoonful  three  times  a  day. 

A  red  cell  count  and  hemoglobin  determination  should  be  made, 
and  if  there  is  anemia,  iron  in  some  form  is  indicated.  Arsenic  may  be 
combined  with  it.  My  favorite  is  Vallet's  mass  and  arsenious  acid,  e.  g.  : 


Massae  Fern  Carbonatis  ......................  10  .  00 

Acidi  Trioxidi  .............................  .  .  .0.045       gr.% 

M.  Massa  fiat.  div.  in  cap.  no.  xxx. 
S.    One  or  two,  three  times  a  day,  after  meals. 

Chronic  Tonsillitis.  This  is  not  a  treatise  on  chronic  conditions, 
but  one  cannot  discuss  tonsillitis  in  any  form  without  voicing  the  danger 
that  lurks  in  a  chronically  infected  tonsil.  The  mere  cataloging  of  such 


88  TREATMENT  OF  ACUTE  INFECTIOUS  DISEASES 

sequences  as  chronic  arthritis,  chronic  nephritis,  rheumatism  or  chorea, 
with  their  endocarditis,  subacute  bacterial  endocarditis,  constant  infec- 
tion of  the  upper  air  passages  with  repeated  colds  and  bronchitis  as  well 
as  otitis  and  adenitis  and  the  suceptibility  of  diseased  tonsil  to  tuber- 
culous infection,  is  plea  enough  for  the  removal  of  such  a  danger  spot. 

It  is  but  a  reversal  of  the  above  statement  to  say  that  the  indications 
for  removal  of  the  tonsils  are: 

1.  When  they  are  causing  obstruction. 

2.  When  they  are  the  seat  of  chronic  infection. 

3.  Repeated  attacks  of  acute  tonsillitis. 

4.  Rheumatic  fever  with  tonsils  infected.   (For  discussion  of  time  for 
removal  see  Acute  Rheumatic  Fever,  Chap.  III.) 

6.  Repeated  infection  of  the  upper  air  passages. 

7.  Chronic   rheumatic    endocarditis,   as   a   prophylactic   measure. 

8.  Chronic  nephritis  or  acute   nephritis  if   secondary  to  tonsilar 
infection. 

9.  Chronic  cervical  adenitis,  tuberculous  or  simple. 

9.  The  operation  is  a  tonsillectomy;  enucleation;  and  all  diseased 
tissue  of  Waldeyer's  ring,  adenoid  and  lingual  tonsil  should  be  removed 
at  the  same  time. 

SUMMARY 

Treatment. 

Confine  patient  to  bed  in  even  a  light  attack. 

Isolate  from  all  of  the  family  who  are  not  acting  in  the  capacity  of 

nurse. 

Make  cultures  and  smears  from  all  sore  throats. 
Administer  diphtheria  antitoxin  to  any  patient  who  has  a  suspicious 

throat  that  cannot  be  cultured  for  any  reason. 

Diet. 

Fluid  or  semi-solid. 

Broths,  cereals,  custards,  jellies,  ice  cream,  and  toast  form  the 
basis  of  such  a  dietary.    (See  Typhoid,  Chap.  XIV.) 

Fluids. 

Water,  alkaline  waters,  fruit  juices  in  such  quantities  as  may  be  taken 
with  comfort. 

Bowels. 

At  the  beginning  of  the  illness  give  a  mild  saline  such  as  Hunyadi 

water. 
May  precede  the  above  by  a  small  dose  of  calomel  gr.  1/KH4  (0.006- 

0.015  Gm.)  at  10-15  minute  intervals  until  a  grain  is  taken. 
Liquor  Magnesii  Citratis,  gviii  (240  c.c.)   or  Epsom,  Rochelle  or 

Glauber's  Salt,  5ss.  (15  Gm.)  may  be  preferred. 


TONSILLITIS  AND  VINCENT'S  ANGINA  89 

Throughout  the  illness  regulate  bowels  with  enemata,  liquid  petro- 
latum, cascara,  aloin,  phenolphthalein  or  a  mild  saline  water. 

Drugs. 

Salicylates  as  sodium  salt,  acetyl  salicylic  acid  (aspirin),  salicin, 
diplosal.  Dosage  gr.  v-x  (0.33-0.66  Gm.)  at  two-hour  intervals  as 
in  rheumatism  (see  Chap.  Ill)  or: 

Tincturae  Aconiti 1 .00  (m.  xvi) 

Sodii  Salicylatis 5.00  (m.  Ixxx) 

Aquae  Destillatae  q.  s.  ad 60.00  (gii) 

M.  et  S.    One  teaspoonful  every  two  hours.    (Delafield.) 

Or  the  coal-tar  preparations  in  the  sthenic  period  for  aches  and  pains. 
Acetanilid,  antipyrin,  acetphenetidin  (phenacetin)  alone  or  com- 
bined with  sodium  bicarbonate  and  citrated  caffeine. 

As 

9 

Acetanilidi 1 . 50        (gr.  xviii) 

Sodii  Bicarbonatis 1 .00        (gr.  xv) 

Caffeinse  Citratae 0.50        (gr.  viiss.) 

M.  et  div.  in  chart,  no.  xv. 

S.  One  every  half  hour  for  four  doses,  then  every  hour  for  four 
doses,  then  every  two  hours  for  an  adult. 

Phenacetin    (acetphenetidin)   double  the  dose  of  acetanilid.      Antipyrin, 
11/2  the  dose  of  acetanilid,  may  be  used  in  solution 

Fever. 

Cool  or  cold  sponges  followed  by  alcohol  rub  if  fever  gives  discomfort. 

Care  of  the  body. 

Daily  sponge  with  castile  soap  and  warm  water. 
Nose  freed  from  secretions  by  cotton  swabs  with  boric  acid  4  per  cent. 

or  Vi  to  %  strength  of  Dobell's  solution. 
Mouth  cleansed  with  same  solutions  on  cotton  applicator  and  sordes 

and  food  particles  removed  from  interstices,  etc.,  with  tooth  picks. 

Insomnia. 

Rest  imperative. 

Milder  hypnotics  usually  sufficient: 
Bromides  gr.  xv  (1  Gm.). 
Trional  gr.  x-xv  (0.66-1  Gm.). 
Chloralamid  gr.  xx  (1.33  Gm.). 

Or  more  potent  preparations  as  barbital  (veronal)  gr.  v-vii  ss.  (0.33- 
0.5  Gm.)  or  barbital  sodium  (medinal)  in  same  doses.  Codeine 
phosphate  gr.  %  (0.015  Gm.)  or  morphine  sulphate  gr.  1/8  (0.008 
Gm.)  hypodermically  if  the  pain  in  the  throat  disturbs  sleep. 

Local  treatment. 

25-50%  solution  of  silver  nitrate  applied  on  a  swab  to  the  tonsils  may 
abort  or  ameliorate  the  process  if  used  in  the  first  few  hours. 


90  TREATMENT  OF  ACUTE  INFECTIOUS  DISEASES 

Guiacol  and  glycerin  equal  parts  may  be  used  for  the  same  purpose 
a*id  in  the  same  way. 

Silver  nitrate  solution  containing  40  to  60  grains  (2.33  to  4  Gm.)  in 
one  ounce  (30  c.c.)  of  water  may  be  used  in  place  of  the  stronger 
soution  and  applied  three  times  a  day.  I  prefer  the  stronger 
solution  in  the  first  12  hours'  followed  by  hot  (110°  F.-1150  F.) 
normal  saline  every  hour  or  two  while  awake.  For  details,  see 
Scarlet  Fever,  Chap.  XVII,  text  and  summary. 

Throat  compress. 

(See  text.) 

Gargles. 

S 

Sodii  Salicylatis 

Sodii  Bicarbonatis 

Sodii  Biboratis aa.  30.00        (5i) 

M.  et  S.    Dissolve  one  teaspoonful  in  three-quarters  glass  of  hot  water. 
Use  as  a  gargle.    (Goodridge.) 

Phenol  solution  1 :100  used  as  a  gargle,  Hare  says,  will  relieve  pain. 
Adenitis,  nephritis,  convalescence,  tonsillectomy.    (See  Scarlet  Fever. 

Chap.  XVII.) 
Pus  may  be  removed  from  crypts  by  suction. 

Heart. 

Should  be  examined  daily  well  into  convalescence.    (See  text.) 

Urine. 

Examine  frequently  during  the  attack  and  in  convalescence.  (See 
text.) 

Septic  sore  throat     (See  text.) 
Circulation.     (See  Scarlet  Fever,  Chap.  XVII.) 
Toxemia.     (See  text  and  Scarlet  Fever,  Chap.  XVII.) 
Complications  and  sequelae.     (See  text.) 
Peritonsillar  abscess.    Incision.     (See  text.) 

Convalescence. 

Do  not  hasten  even  after  a  light  attack.  Fresh  air,  good  food,  a 
simple  tonic  such  as  strychnine  sulphate  gr.  1/60-1/30  (0.001-.002 
Gm.)  three  times  a  day,  or: 

$ 

Tr.  Nucis  Vomicse 20        (5v) 

Sodii.  Glycerophosphatis 20        (5v) 

. Aq.  dest.  q.  s.  ad 120        (5iv) 

M.  et  S.    One  teaspoonful  three  times  a  day. 

" .   If  anemic,  give  iron  or  iron  and  arsenic  as  Vallet's  mass  and  arsenious 
acid. 


TONSILLITIS  AND  VINCENT'S  ANGINA  91 

a 

Massae  Ferri Crabonatis 10.00  (Siiss.) 

Acidi  Trioxidi 0.0045        (gr.  %) 

Massa  fiat,  div.  in  cap.  no.  xxx. 
S.    One  or  two  three  times  a  day. 

Chronic  tonsillitis. 

Enucleation  of  the  tonsils  and  the  complete  removal  of  the  adenoid 
tissue  in  Waldeyer's  ring. 

VINCENT'S  ANGINA 

This  condition,  which  is  not  infrequently  encountered  and  diag- 
nosed as  either  acute  foUicular  tonsillitis  or  diphtheria,  is  on  the  tonsil 
but  a  local  expression  of  what  may  be  a  more  widespread  oral  infection 
and  in  some  instances  an  uncontrollable  and  fatal  one,  called  noma  or 
cancrum  oris.  It  will  be  briefly  described  here.  The  affection  is  char- 
acterized by  the  formation  of  a  necrotic  membrane  that  most  commonly 
is  found  upon  the  tonsils,  though  by  no  means  confined  to  these  struc- 
tures as  it  may  invade  the  fauces,  gums,  cheeks  and  indeed  any  part  of 
the  mouth,  pharynx  and  in  rarer  instances  larynx,  trachea  or  bronchi. 

It  simulates  closely  one  of  two  conditions  and  to  one  unfamiliar  with 
Vincent's  angina  the  error  in  diagnosis  is  almost  invariable;  when  super- 
ficial it  will  be  called  diphtheria  and  when  ulcerative,  and  it  is  often  a 
deep,  punched  out  ulcer,  it  will  be  called  syphilitic. 

The  membrane  simulating  diphtheria  is  ashy  gray  or  has  a  yellowish  or 
even  greenish  tinge,  is  easily  removable  and  then  discloses  the  bleeding 
surface  of  the  superficial  ulceration.  When  the  ulcers  are  deep  they  are 
found  filled  with  a  gray  pultaceous  material  and  both  forms  untreated 
are  curiously  persistent. 

In  the  severe  types,  occurring  especially  after  measles  or  in  the  course 
of  certain  blood  diseases,  notably  leukaemia,  the  extent  and  swiftness 
of  the  process  is  appalling;  soft  tissue  and  bones,  cheeks,  gums,  alveolar 
processes,  melting  before  its  advance. 

In  the  mild  cases  there  are  not  many  general  symptoms,  only  a  very 
trifling  rise  of  temperature;  the  one  symptom  being  the  persistent  sore 
throat;  but  in  the  severe  type  intoxication  ensues  with  fatal  results.  The 
organisms  concerned  in  this  necrosis  are  easily  detectable  and  so  char- 
acteristic that  they  cannot  be  mistaken.  There  is  a  fusiform  bacillus 
(bacillus  fusiformis),  it  is  double  pointed,  thicker  in  the  middle  and  often 
of  a  beaded  or  barred  appearance  from  deep  staining  of  granules. 

These  fusiform  bacilli  are  always  accompanied  by  spirilla  that  look 
like  the  spirochetae  pallidae  but  have  fewer  twists  and  wider  spirals. 

It  has  not  yet  been  definitely  determined  whether  the  occurrence  of 
these  two  forms  constitute  a  symbiosis  or  whether  they  are  different 


92  TREATMENT  OF  ACUTE  INFECTIOUS  DISEASES 

stages  in  the  development  of  a  single  organism.  They  are  found  in 
normal  mouths  where  they  seem  to  be  saprophytic,  but  under  certain 
conditions  become  pathogenic. 

The  conditions  that  determine  pathogenicity  in  these  organisms, 
are  an  unhygienic  mouth,  neglected  teeth,  tne  lowered  resistance  ac- 
companying or  following  certain  diseases,  as  leukaemia,  measles,  scar- 
let fever,  diphtheria. 

Treatment.  Milder  cases  only  require  local  treatment  and  the 
prompt  manner  in  which  a  long  standing  and  annoying  condition  yields 
to  simple  procedures  is  most  satisfactory. 

Remove  the  membrane  with  a  swab  dipped  in  1  per  cent,  co- 
caine hydrochloride  as  the  ulcerations  are  sensitive,  often  exquisitely  so, 
and  apply  directly  to  the  ulcer  one  of  the  following  substances: 

Chromic  Acid,  5  per  cent,  solution.  This  is  one  of  the  best  ap- 
plications. Repeat  daily  until  the  ulcer  heals. 

Silver  Nitrate,  10  per  cent,  to  25  per  cent,  solution  applied  in  the 
same  manner. 

Zinc  Sulphate,  5  per  cent,  solution.  I  have  had  no  experience 
with  this  application. 

Tincture  of  Iodine.  This  is  applicable  in  the  milder  cases  and 
on  small  areas. 

With  all  this,  proper  care  of  the  mouth  must  be  instituted.  The 
dentist  should  be  consulted  and  all  affected  teeth  receive  proper  treat- 
ment. A  neglect  of  these  precautions  invites  relapse. 

As  malnutrition  and  the  lowered  state  induced  by  infectious  diseases 
are  predisposing  factors,  a  sufficiency  of  a  properly  selected  diet  is  of  first 
importance  in  these  conditions,  together  with  fresh  air  and  sunlight. 

Severe  Cases.  When  the  necrosis  is  deep  and  rapid  the  condi- 
tion is  appalling  and  as  unyielding  as  the  milder  cases  are  yielding. 

Salvarsan  is  indicated  in  these  cases.  The  technique  and  dos- 
age is  the  same  as  in  syphilis.  The  success  that  meets  the  use  of  arsenical 
compounds  speaks  for  the  spirochetal  nature  of  the  infecting  organism. 

Cancrum  oris  is  discussed  under  the  heading  of  Measles,  Chap.  XIX, 
where  the  radical  measures  to  stay  the  process  are  detailed. 

SUMMARY 

Mild  cases. 

Do  not  require  confinement  to  bed,  nor,  in  the  absence  of  constitutional 
manifestations,  to  the  house. 

Local  treatment. 

Remove  membrane  with  swab  dipped  in  1  per  cent,  cocaine  to  relieve 
pain  of  the  procedure. 


TONSILLITIS  AND  VINCENT'S  ANGINA  93 

Applications. 

Chromic  acid,  5  per  cent,  solution  to  the  bared  ulcer  daily  until  heal- 
ing is  established. 
Silver  nitrate,  10  per  cent,  to  25  per  cent,  solutions,  in  the  same 

manner. 

Zinc  sulphate,  5  per  cent,  solution  in  the  same  manner. 
Tincture  of  iodine:  on  small  areas. 

Oral  hygiene. 

Dental  supervision. 

Abundant  diet  in  cases  of  malnutrition  and  convalescence  from  in- 
fectious diseases. 

Fresh  air  and  sunlight. 

Severe  cases. 

Confine  to  bed. 

For  choice  of  bed,  room,  care  of  body  and  maintenance  of  the 
circulation  see  Pneumonia,  Chap.  IX. 

Salvarsan. 
Technique  and  dosage  same  as  in  syphilis. 

Cancrum  oris. 

Radical  surgical  procedure.     (See  same  under  Measles,  Chap.  XIX.) 
Bismuth  subnitrate  paste.     (See  Measles,  Chap.  XIX.) 


CHAPTER  VI 

ACUTE  LARYNGITIS 

THE  larynx  may  be  the  seat  of  an  acute  inflammation,  either  as  a  pri- 
mary process  or  secondary  to  or  a  part  of  an  infection  elsewhere  in  or 
general  throughout  the  respiratory  tract.  It  may  then  be  found  with  a 
tracheitis  or  bronchitis  or  an  item  in  a  "cold"  or  "sore  throat." 

If  patients  are  prone  to  laryngitis  we  suspect  foci  of  infection  in  tonsils, 
adenoids,  especially  in  children,  and  in  sinuses  or  nasal  passages.  Irri- 
tating gases  can  produce  a  very  acute  inflammation. 

Predisposing  causes  are  to  be  found  in  exposure  to  cold,  damp  and 
high  winds  and  excessive  use  of  the  voice.  Not  infrequently  the  attacks 
seem  to  have  some  connection  with  indigestion  and  are  prone  to  occur 
in  the  gouty. 

Symptomatology.  Sore  throat,  more  marked  on  swallowing,  with 
hoarseness  and  cough,  and  in  severe  cases  pain,  are  the  chief  symptoms. 
In  young  children  from  1  to  5  years  of  age  there  is  commonly  in  addition 
to  the  catarrhal  inflammation  a  laryngeal  spasm,  due  to  reflex  irritability, 
a  spasmodic  croup  with  a  harsh,  hollow  or  metallic  quality  to  the  cough, 
dyspnoea  and  inspiratory  stridor.  During  the  attack  the  child  may  look 
desperately  ill  and  always  sounds  a  note  of  alarm  to  the  parent  who  sees 
it  for  the  first  time.  It  is  always  more  severe  at  night,  a  remission  occur- 
ring during  the  day,  beginning  with  the  early  morning  hours. 

There  may  be  a  slight  temperature,  especially  in  children,  of  100°  F. 
to  101°  F. 

The  laryngoscope  discloses  a  redness  of  the  mucosa  and  swelling  and 
redness  of  the  vocal  cords. 

This  is  not  the  place  to  go  into  detail  of  differential  diagnosis,  but  one 
must  keep  in  mind  tuberculosis  of  the  larynx  with  its  ulceration  of  cords 
and  arytenoids;  syphilis  with  its  gummatous  infiltration;  edema  of  the 
glottis  and,  in  children,  diphtheria.  Croup  carrying  on  into  the  day 
should  be  labeled  diphtheria  and  the  practitioner  is  wise  to  take  a  culture 
in  all  cases  of  croup.  In  infants,  with  manifestations  of  rickets,  laryn- 
gismus  stridulus  is  to  be  thought  of.  The  general  practitioner  must  be  as 
familiar  with  the  laryngoscope  as  he  is  with  the  stethoscope.  These 
instruments,  with  the  otoscope  and  ophthalmoscope,  are  as  much  a  part 
of  the  equipment  of  the  general  practitioner  as  of  the  specialist.  The 


ACUTE  LARYNGITIS  95 

former  can  read  headlines  with  them,  if  not  fine  print  and  from  headlines 
we  gain  the  essential  news. 

Treatment.  Rest;  rest  of  the  body  at  large  and  rest  of  the  or- 
gan concerned.  The  patient  should  be  ordered  to  bed;  ordered  because, 
perchance  deeming  it  a  matter  of  no  great  importance,  he  will  not  listen 
to  language  that  is  hortatory,  but  only  to  that  expressed  in  the  imper- 
ative. 

To  rest  the  organ  involved  the  patient  should  be  instructed  not  to 
talk,  and  what  is  of  equal  importance  the  people  about  him  should  be 
ordered  not  to  make  him  talk  more  than  is  absolutely  necessary  and  then 
in  a  whisper. 

Smoking  during  the  attack  should  be  forbidden,  an  injunction  illy 
received  by  the  confirmed  cigarette  smoker.  Irritating  smoke  or  gases 
must  be  avoided,  even  if  it  necessitates  removal  of  the  patient  from 
the  environment. 

Bowels.  A  free  catharsis  should  be  administered  at  the  begin- 
ning of  the  attack,  either  one  of  the  well-known  salts,  Epsom  (magne- 
sium sulphate),  Rochelle  (sodium  and  potassium-tartrate),  Glauber's 
(sodium  sulphate)  or  sodium  phosphate  in  doses  of  5  ss.  (15  Gm.)  in 
%  glass  water  or  full  doses  of  one  of  the  many  saline  cathartics  on  the 
market  of  the  type  of  Hunyadi  water;  later,  milder  doses  or  enemata 
may  be  relied  upon. 

Abortive  Treatment.  A  hot  full  bath  or  a  hot  foot-bath  or  a 
hot  mustard  foot-bath  is  often  taken  to  abort  the  process  and  in  my 
estimation  is  seldom  or  never  successful,  but  the  patient  may  be  rendered 
more  comfortable  by  the  process. 

If  a  full  bath  is  taken  the  patient  must  get  at  once  into  a  warm  bed 
preferably  between  blankets  or  into  a  flannel  night  dress  or  pajamas, 
have  a  hot  water  bottle  put  at  the  feet  and  take  hot  drinks;  weak  tea, 
hot  lemonade  to  which  a  dash  of  whisky  may  or  may  not  do  more  than 
break  the  drought.  The  same  precautions  should  be  taken  with  the 
foot-baths,  as  the  object  is  to  induce  a  gentle  perspiration,  which  in  a 
cold  bed  and  a  cold  room  and  cotton  night  clothes  might  well  aggra- 
vate the  condition. 

The  mustard  foot-bath  is  prepared  as  follows: — 

"  Mustard  Baths  and  Foot-Baths.  To  prepare  a  mustard  bath  or  foot- 
bath: Dissolve  mustard  in  hot  water  in  the  proportion  of  two  table- 
spoons of  the  former  to  a  gallon  of  the  latter.  Stir  well  just  before 
giving  the  bath. 

"  To  give  a  foot-bath:  Fold  the  bed-clothes  up  from  the  foot  of  the 
bed  to  above  the  patient's  knees,  replacing  them  with  a  double  blanket. 
(Be  careful  not  to  expose  the  patient  while  doing  this.)  Turn  part  of  the 


96  TREATMENT  OF  ACUTE  INFECTIOUS  DISEASES 

doubled  blanket  over  the  feet  and  back  under  the  legs.  Flex  the  knees 
and  place  the  foot  tub,  half  filled  with  water  115°  F.,  lengthwise  on 
the  bed,  between  the  folds  of  the  blanket.  Lift  the  feet  with  one  hand 
and,  with  the  other,  draw  the  tub  under  them.  Put  them  into  the  water 
slowly,  that  they  may  become  gradually  accustomed  to  the  high 
temperature.  Fold  the  blanket  around  the  tub  and  knees,  and  bring 
down  the  bed-clothes.  In  about  ten  minutes  add  hot  water,  being 
careful  not  to  pour  it  in  near  the  feet.  The  bath  lasts  about  twenty 
minutes.  Take  out  the  feet  in  the  same  manner  as  you  put  them  in, 
drying  them  well,  and  place  a  hot-water  bag  against  them."  Maxwell 
and  Pope,  Practical  Nursing. 

In  the  early  dry  stage  the  cough  is  irritating  and  painful  and  sedative 
measures  are  indicated : 

Inhalations.  The  inhalation  of  plain  steam  is  gratifying  or  one 
may  add  compound  tincture  of  benzoin,  oil  of  pine  or  oil  of  eucalyptus, 
5i-5ii  (4-8  c.c.)  on  the  surface  of  the  water.  One  may  use  one  of  the 
many  inhalers  on  the  market,  some  of  which  are  very  inexpensive,  or 
devise  one  from  a  kettle,  pitcher  or  carafe  to  which  a  cone  is  affixed,  made 
of  a  roll  of  stiff  paper  by  which  the  steam  is  led  to  the  face  of  the  patient, 
lying  on  his  side. 

In  children  a  croup  kettle,  one  of  the  best  of  which  is  that  devised  by 
Holt,  is  the  safest  and  most  convenient.  The  child  may  be  put  into  a 
tent  made  by  a  sheet  thrown  over  the  head  of  the  bed,  to  the  post  of 
which  laths  may  be  attached  to  give  elevation  or  over  a  clothes  horse 
placed  about  the  head  of  the  bed  or  even  over  an  open  umbrella.  Chil- 
dren must  not  be  kept  for  long  periods  in  these  confined  spaces,  the 
damp,  warm  air  of  which  becomes  depressing. 

In  the  early  stages  the  drug  which  seems  to  afford  the  most  relief 
is  ipecac.  A  good  prescription  is  as  follows : 

(Adult  dose) 

J%— Vini  Ipecac 10.00        (Siiss.) 

Potassii  Acetatis 10. 00        (Siiss.) 

Aquae  q.  s.  ad 120.00        (giv.) 

M.  et  S.  5ii  (2  teaspoonfuls)  every  three  hours. 

A  favorite  prescription  of  the  late  Dr.  Francis  Delafield  was  tartar 
emetic  and  ipecac  each  gr.  1/100  (0.0006  Gm.)  every  half  hour. 

Cough.  If  the  cough  is  excessive  one  may  have  recourse  to 
codeine  in  doses  of  gr.  1/8-Ji  (0.008-0.015  Gm.)  of  the  phosphate,  or 
heroine  in  doses  of  gr.  1/16-gr.  1/12  (0.004-0.005  Gm.)  of  the  hydro- 
chloride.  It  is  only  the  exceptional  case,  that  not  yielding  to  the  above 
measures  and  losing  sleep,  requires  morphine  sulphate  in  gr.  1/8  (0.008 


ACUTE  LARYNGITIS  97 

Gm.)  doses  hypodermically.  A  local  application  of  equal  parts  of 
spirits  of  turpentine,  spirits  of  camphor  and  olive  oil,  well  mixed  and 
sprinkled  liberally  on  a  square  of  flannel,  laid  upon  the  chest  and  pinned 
to  the  night  clothes  may  be  found  to  ameliorate  the  cough. 

Local  Treatment.  Cold  compresses  to  the  larynx  are  often 
effectual.  They  should  be  applied  as  described  by  Baruch  in  his  Hy- 
drotherapy. 

11  The  Wet  Compress,  Technique.  Two  or  more  folds  of  old  linen,  thin  or 
thick  as  may  be  required,  and  of  the  necessary  size  and  shape  to  conform 
to  the  part  which  is  to  be  treated,  are  formed  into  a  compress.  Cotton 
cloth  is  objectionable  because  it  does  not  receive  or  hold  moisture  so 
well.  If,  however,  linen  is  not  available,  the  oldest  and  most  worn 
cotton  cloth  should  be  selected.  The  compress  is  wrung  out  of  water 
of  the  required  temperature  (60°-75°  F.)  and  is  covered  with  flannel  or 
with  a  dry  piece  of  linen  of  the  same  shape,  but  an  inch  or  two  wider  and 
of  sufficient  length  to  secure  the  wet  cloth  snugly  when  pinned.  It  is  a 
sine  ua  qnon  of  the  cold  wet  compress  that  air  be  excluded  from  it,  be- 
cause the  vaporization  of  water  contained  in  it  by  warmth  of  the  skin 
renders  the  latter  extremely  sensitive  to  chilling,  which  is  the  usual 
result  of  the  imperfectly  applied  compress.  The  compress  is  renewed 
every  hour  as  a  rule,  but  this  depends  on  each  individual  case.  Before 
removal  a  fresh  compress  should  be  laid  in  readiness.  A  cardinal  rule  to 
guide  in  the  renewal  of  the  compress,  applicable  in  all  cases,  is  that  the 
latter  should  be  warm  before  removal.  If  it  has  not  been  warmed  by  an 
hour's  apposition  with  the  skin,  it  must  either  remain  or  be  removed 
without  renewal." 

Ice  Collar.  A  special  ice  bag  made  to  apply  as  a  collar  may 
be  used. 

For  technique  in  filling  the  bag  and  its  application,  see  Pneumonia, 
Chapter  IX. 

Fomentations.  Application  of  fomentation.  Cut  two  or  three 
thicknesses  of  flannel,  sufficiently  large  to  surround  the  neck.  This 
flannel  is  placed  in  a  crash  towel,  boiling  water  poured  upon  it,  the  ends 
of  the  towel  twisted  in  opposite  directions  to  squeeze  the  water  from  the 
flannel.  The  skin  is  smeared  with  vaseline  or  sweet  oil  and  the  flannels 
applied  with  dry  flannels  outside,  all  of  which  are  kept  in  place  by  a 
binder.  These  are  replaced  as  fast  as  they  become  cool.  Care  must 
be  taken  that  not  enough  hot  water  is  left  in  them  to  drip  down  upon 
the  skin  and  burn. 

Sprays.  Perhaps  the  best  spray  is  one  containing  menthol  gr. 
ii  in  5i  of  liquid  petrolatum  (albolene). 


98  TREATMENT  OF  ACUTE  INFECTIOUS  DISEASES 


Ac.  Carbolic!  (Phenol)  .......................  gr.  iii  0.20 

Menthol  ........  ............................  gr.  v  0.33 

Benzoinol  ............................  ,  ____  3i  30.00 

M.  et  ?.    Spray  the  throat  while  taking  a  deep  breath. 

In  children  steam  or  medicated  inhalations  as  above  are  indicated. 
Hot  fomentations,  using  the  technique  given  above,  and  small  doses 
of  ipecac  and  tartar  emetic  aa  gr.  1/100  (0.0006  Gm.)  at  4  to  6  hour 
intervals  and,  if  there  is  spasm,  antipyrin  gr.  i  (0.060  Gm.)  and  sodium 
bromide  gr.  iii  (0.20  Gm.)  to  a  dram  of  water  4  c.c.)  may  be  given  at 
four-hour  intervals. 

The  spasmodic  croup  is  interrupted  by  the  use  of  emetics,  the  safest 
and  best  is  syrup  of  ipicac  in  teaspoonful  doses  at  15  minute  intervals 
until  vomiting  occurs.  There  is  rarely  occasion  for  alarm,  unless  the 
croup  is  diphtheritic. 

Complications.  The  one  of  alarming  significance  is  edema  of 
the  larynx,  more  commonly  occurring  after  the  inhalation  of  irritating 
gases. 

The  measures  for  relief  must  be  prompt.     They  are: 

Scarification.  "When  the  dyspnea  is  severe  no  time  should 
be  lost  in  scarifying  the  edematous  tissue.  This  should  be  done  by  first 
spraying  the  back  of  the  throat  freely  with  a  20  per  cent,  solution  of 
cocaine,  and  instructing  the  patient  to  swallow  any  excess  of  the  fluid,  so 
that  some  of  the  solution  may  bathe  the  edematous  tissue  in  the  arye- 
piglottic  folds.  A  cotton-wound  laryngeal  applicator  should  be  dipped 
in  a  20  per  cent,  solution  of  cocaine  and  the  swollen  region  of  the  larynx 
brushed  with  the  solution,  the  tongue  being  protruded  and  the  laryngeal 
mirror  employed  in  order  to  paint  accurately  the  swollen  areas.  Some- 
times the  edema  will  be  markedly  diminished  owing  to  the  constringent 
action  that  this  drug  has  upon  the  mucous  membrane.  It  is  not  safe  to 
rely  upon  this  entirely,  for  in  an  hour  or  so,  when  the  effects  of  the  co- 
caine have  passed  off,  the  edema  usually  reappears  in  a  more  aggravated 
form.  Five  minutes  after  the  cocainization  the  parts  should  be  well 
illuminated  with  a  laryngeal  mirror  and  a  curved,  concealed  laryngeal 
knife  should  be  introduced,  the  knife  being  concealed  during  the  intro- 
duction, and  only  pushed  forward  to  scarify  the  tissues  when  it  has 
reached  the  areas  of  greatest  swelling.  Hemorrhage  and  transudation  of 
serum  follow,  the  swelling  diminishes,  and  respiration  becomes  easier. 
If  this  procedure  does  not  diminish  the  edema  and  cyanosis  deepens, 
then  tracheotomy  should  be  promptly  performed."  Coakley,  Diseases 
of  the  Nose  and  Throat. 


ACUTE  LARYNGITIS  99 

Intubation.  (For  technique  see  section  under  Diphtheria  (Chan 
XVIII.) 

Tracheotomy.  If  this  operation  is  to  be  performed,  a  text- 
book on  surgery  should  be  consulted. 

SUMMARY 
Treatment. 

Rest  of  the  body  at  large  and  of  the  organ  concerned  is  imperative. 

If  speaking  is  necessary,  do  so  in  a  whisper. 
Smoking  is  forbidden. 
Irritating  smoke  or  gases  must  be  avoided. 

Bowels. 

An  initial  catharsis  with  a  saline,  e.  g.,  Epsom,  Rochelle  or  Glauber's 

salt  in  doses  gss.  (15  Gm.)  in  %  glass  water. 
Later,  enemata  or  milder  salines. 

Abortive  treatment. 

Hot  full  bath  or  hot  foot-bath  or  hot  mustard  foot-bath  may  abort 

the  process.    Technique  —  see  text. 
Follow  by  going  to  bed  at  once  between  hot  blankets  or  in  warm 

flannel  night  clothes  with  hot  water  bag  at  feet. 
Take  hot  drinks  such  as  lemonade  containing  whisky. 

Inhalations. 

Plain  steam  or  add  compound  tincture  of  benzoin,  oil  of  pine  or  oil 
of  eucalytus  5i~ii  (4-8  c.c.)  to  the  water  in  an  inhaler  or  in  a  kettle, 
pitcher,  carafe,  etc.,  to  which  is  attached  a  cone  of  stiff  paper  by 
which  steam  is  led  to  the  patient's  face.  For  children  the  Holt 
Croup  Kettle  is  best,  or  use  a  tent.  (See  text.) 

Ipecac,  best  drug  in  early  stages. 


Vini  Ipecac  ..............................  10.00        (Siiss.) 

Potassii  Acetatis  .........................   10.00        (Siiss.) 

Aquae  q.  s.  ad  ............................  120.00        (Siv.) 

M.etS.    Two  teaspoonfuls  every  three  hours  for  an  adult.   OrDel- 

afield's  favorite  prescription  of  tartar  emetic  and  ipecac,  each 

gr.  1/100  (0.0006  Gm.)  given  every  half  hour. 

Cough. 
If  excessive,  give  codeine  phosphate  gr.  1/8-1/4  (0.008-0.015  Gm.) 

or  heroine  hydrochloride  gr.  1/16-1/12  (0.004-0.005  Gm.). 
For  loss  of  sleep  due  to  cough  not  yielding  to  above,  morphine  sul- 

phate gr.  1/8  (0.008  Gm.)  hypodermically. 
Local  application  of  oil  of  turpentine,  spirits  of  camphor  and  olive 

oil  equal  parts  on  a  warm  flannel  laid  on  the  chest  and  pinned  to 

the  night  clothes. 


100  TREATMENT  OF  ACUTE  INFECTIOUS  DISEASES 

Local  treatment. 

Cold  compresses  to  the  larynx.    (See  text.) 
Ice  collar.    (See  text.) 
Hot  fomentations.    (See  text.) 

Sprays. 

Menthol  gr.  ii  (0.120  Gm.)  in  5  i  (30  c.c.)  of  liquid  petrolatum  (albo- 
lene)  or 

8 

Ac.  Carbolici gr.  iii 

Menthol gr.  v 

Benzoinol 5  i 

M.  et  S.   Spray  the  throat  while  taking  a  deep  breath."    (Coakley.) 

For  children. 

Inhalations  as  given  above. 

Ipecac  and  tartar  emetic  of  each  gr.l/100(0.0006  Gm.)  every  4-6 

hours. 
If  there  is  spasm  give  antipyrin  gr.  i  (0.060  Gm.)  and  sodium  bromide 

gr.  iii  (0.20  Gm.)  to  a  dram  (4  c.c.)  of  water  every  4r-6  hours. 

Complications. 

Edema  of  the  larynx. 

Scarification.    (See  text.) 

Intubation.    (See  Diptheria,  Chap.  XVIII.) 

Tracheotomy.    Consult  special  surgery  text-book. 


CHAPTER  VII 

ACUTE  BRONCHITIS  AND  TRACHEITIS 

THESE  conditions  will  be  considered  together  as  the  processes  are 
identical  and  the  terms  are  merely  referable  to  regional  distribution. 
The  pathology  consists  of  a  catarrhal  inflammation  of  the  whole  bron- 
chial tree  with  a  thick  mucoid  exudation,  becoming  thinner  as  the 
process  advances  toward  resolution  or  becoming  muco-purulent.  It  is 
usually  confined  to  the  larger  and  medium  sized  tubes;  but  in  children 
and  the  elderly  is  prone  to  involve  the  smaller  bronchi,  when  it  is  spoken 
of  as  a  capillary  bronchitis,  and  is,  indeed,  a  broncho-pneumonia,  though 
the  areas  of  consolidation  may  be  too  small  to  give  it  the  physical  signs. 
Not  infrequently  the  process  is  limited  to  the  trachea  (tracheitis)  and 
the  larger  tubes;  commonly  the  infection  begins  as  a  coryza  and  spreads 
downward,  involving  the  larynx  in  its  progress. 

The  bronchial  involvement  is  always  bilateral  though  in  exceptional 
instances  physical  signs  may  be  confined  to  one  side  and  to  a  limited 
region.  When  these  signs  are  so  limited  it  is  not  justifiable  to  make  a 
diagnosis  of  bronchitis  until  broncho-pneumonia  and  tuberculosis  are 
excluded.  If  localized  bronchitis  occurs  at  the  bases,  the  diagnosis 
should  be  broncho-pneumonia,  if  in  the  upper  lobe,  tuberculosis  and  more 
particularly  at  the  apices;  but  broncho-pneumonia  and  a  so-called  grip 
pneumonia,  a  partial  consolidation  of  the  lobar  type,  may  affect  one 
upper  lobe  to  simulate  closely  a  tuberculosis.  The  infecting  organisms 
may  be  the  influenza  bacillus,  pneumococcus,  streptococcus,  micrococcus 
catarrhalis  and  more  rarely  others. 

The  inhalation  of  irritating  gases  may  be  the  direct  cause,  as  was 
witnessed  on  so  large  a  scale  amid  the  barbarities  of  the  late  war. 

Among  the  predisposing  causes  are  exposures  to  wet  and  cold,  causing 
chilling,  to  which  fatigue  contributes,  hence  its  frequency  in  Spring  and 
Autumn  with  their  sudden  changes,  overheating  of  rooms,  overdressing, 
close  confinement;  causing  sluggish  vaso-motor  response  when  exposed 
to  cold.  In  children,  adenoids  and  hypertrophied  tonsils  predispose  to 
infection.  (Holt.) 

The  immediate  cause  in  the  vast  majority  of  instances  is  direct  expo- 
sure to  infection  from  others  suffering  from  coryza  and  bronchitis, 
especially  in  crowded  conveyances  and  places  of  amusement. 

Bronchitis,  too,  is  a  common  and  early  accompaniment  of  several 


102  TREATMENT  OF  ACUTE  INFECTIOUS  DISEASES 

•rifcfect<o<is  •  diseases,  typhoid  fever,  malaria,  measles,  whooping  cough. 
Tuberculosis,  we  are  reminded,  may  begin  as  an  acute  bronchitis.  (Nor- 
ris  and  Landis.) 

Symptoms  vary  with  the  severity  and  extent  of  the  process. 
The  one  cardinal  symptom  is  cough.  This  cough  is  at  first  dry;  if  the 
trachea  is  much  inflamed  it  is  racking  and  persistent  and  accpmpanied 
by  a  sense  of  soreness  under  the  sternum  and  some  oppression  in  that 
region.  A  coryza  may  or  may  not  have  preceded  the  cough.  There  are 
general  symptoms  of  malaise  and  aches  and  pains,  as  after  a  mild  grip, 
but  they  are  not  a  feature.  Fever  may  be  trivial  or  rise  to  102°  F.  or 
103°  F.  or  higher  if  the  small  bronchi  are  involved.  As  the  process  pro- 
gresses the  cough  becomes  looser  and  a  mucoid  or  muco-purulent  ex- 
pectoration follows. 

Physical  Signs  are  such  as  are  determined  almost  exclusively 
by  auscultation.  They  are  prolongation  of  expiration  and  rales,  at  first 
sibilant,  later  moist. 

Treatment.  A  bronchitis,  unless  very  widespread  or  a  capillary 
bronchitis  (broncho-pneumonia),  is  too  often  looked  upon  as  a  trivial 
affair.  That  in  children  it  may  be  the  precursor  of  measles  or  whooping 
cough  or  in  adults  an  early  manifestation  of  typhoid  or  tuberculosis 
should  make  us  cautious;  but  if  a  primary  process,  it  may,  through 
neglect,  lead  to  pneumonia  or  go  into  a  chronic  form,  with  the  disagree- 
able sequences  of  bronchiectasis,  emphysema  and  asthma. 

The  patient  should  certainly  be  confined  to  the  house  and,  if  there  is 
any  febrile  reaction,  to  the  bed  until  it  has  subsided  for  at  least  three 
days. 

If  the  process  is  intense  and  the  small  bronchi  and  bronchioles  are 
involved  the  case  should  be  treated  as  a  pneumonia.  (See  Chap.  IX.) 

Room.  The  room  should  be  chosen  with  reference  to  a  suffi- 
cient ventilation  and  access  to  sunlight.  No  matter  how  mild  the  case, 
it  should  not  be  shared  with  another  person  for  sleeping  purposes.  Dry 
sweeping  should  never  be  allowed  in  a  sick  room;  damp  cloths  should  be 
used.  Smoking  should  not  be  allowed.  It  seems  ludicrous  that  the 
warning  should  have  to  be  made;  but  to  anyone  who  has  had  to  treat 
the  confirmed  cigarette  smoker  it  will  seem  less  ludicrous  than  difficult. 
The  habit  of  inhalation,  practically  universal  among  cigarette  smokers, 
gives  rise  to  further  irritation  of  the  inflamed  air  passages  and  also  an- 
tagonizes the  physician's  best  efforts. 

Talking  should  be  discouraged,  as  it  aggravates  the  cough  and  en- 
courages spread  to  the  smaller  bronchi. 

In  milder  cases  a  specially  selected  bed,  so  desirable  in  long  and  serious 
infections,  is  not  imperative. 


ACUTE  BRONCHITIS  AND  TRACHEITIS  103 

Diet.  Except  in  severe  cases  no  peculiar  modification  in  the  usual 
diet  is  necessary.  In  severe  cases  the  diet  is  arranged  as  in  pneumonia. 

Precautions.  It  must  be  remembered  that  bronchitis  is  an  in- 
fectious disease  and  that  the  infection  is  conveyed  by  the  secretions  of 
the  patient.  For  the  safety  of  the  family,  isolation  is  highly  desirable. 
Certainly  during  the  early  days  of  the  acute  process  it  is  well  to  keep 
all  members  of  the  family  except  those  who  act  in  the  capacity  of  nurse, 
and  certainly  all  visitors,  out  of  the  sick  room.  Members  of  the  family 
and  the  patient  should  be  told  that  coughing,  sneezing  and  even  conver- 
sation at  close  range  convey  the  infection  as  a  fine  spray  through  several 
feet  distance;  that  kissing,  petting,  hand-shaking,  contact  with  the 
patient's  soiled  linen,  towels  and  handkerchiefs,  with  table  utensils, 
convey  the  infection  directly.  This  information  warns  others  from 
unnecessary  contact  and  instructs  the  patient  to  cover  the  mouth  and 
nose  when  coughing  and  sneezing. 

All  the  secretions  and  expectorations  should  be  caught  on  pieces  of 
gauze  or  old  cloths,  placed  in  a  paper  bag  and  burned.  Handkerchiefs 
and  linen  should  be  immersed  in  water  until  such  time  as  they  can  be 
boiled  to  sterilize  them;  table  utensils  should  be  boiled  and  kept  separate 
and  a  separate  thermometer  kept  for  the  patient  and  when  not  in  use 
should  be  immersed  in  an  antiseptic  solution,  e.  g.  carbolic  acid,  1  to  20. 

Early  Measures.  It  has  long  been  a  habit  of  the  layman,  en- 
couraged by  the  physician,  to  try  to  abort  a  "  cold  "  by  taking  a  hot  bath, 
getting  to  bed  between  warm  blankets,  putting  a  hot  water  bag  or  bottle 
at  the  feet  and  taking  a  hot  drink  to  encourage  perspiration.  I  have 
never  convinced  myself  that  an  infection  could  be  so  aborted,  but  it  may 
relieve  the  discomforts  incident  upon  a  beginning  infection.  Unless, 
however,  a  warm  bed  and  its  accessories  are  at  hand,  a  hot  bath  followed 
by  chilling  may  do  great  harm. 

Bowels.  It  is  well  to  move  the  bowels  with  a  mild  saline; 
one  of  the  many  laxatives  on  the  market  of  which  Hunyadi  water  is  a 
type,  or  with  liquor  magnesii  citratis  5viii  (240  c.c.)  or  moderate  doses 
3ii-iv  (8  to  15  Gm.)  of  Epsom  salt,  sodium  sulphate  (Glauber's  salt), 
Rochelle  salt  or  sodium  phosphate. 

Headaches  and  General  Aches  and  Pains.  These  are  not  con- 
stant and  as  a  rule  not  severe.  My  custom  is  to  use  small  but  frequent 
doses  of  acetanilid/ which  I  usually  prescribe  in  this  form. 

3 

Acetanilid? 1 . 50        gr.  xxnss. 

Sodii  Bicarbonatis 1.00        gr.  xv 

Caffeinse  CitrataB 0.50        gr.  viiss. 

M.  et  div.  in  capsulas  no.  xv. 
S.  As  directed. 


104  TREATMENT  OF  ACUTE  INFECTIOUS  DISEASES 

These  capsules  are  given  at  half  hour  intervals  until  four  are  given 
and  then  every  two  hours.  They  are  continued  only  during  the  first 
24  hours.  For  the  same  purpose  acetphenetidin  (phenacetin)  in  three 
grain  (0.20  Gm.)  doses,  combined  with  bicarbonate  of  soda  and  citrated 
caffeine  in  the  doses  given  above  may  be  used.  If  it  is  desired  to  give 
medicine  in  solution,  antipyrin  in  2  grain  doses  (0.120  Gm.)  may  be 
substituted.  If  the  headache  is  severe  single  large  doses  may  be  admin- 
istered, e.  g.,  acetphenetidin  (phenacetin)  gr.  x  (0.66  Gm.)  with  citrated 
caffeine  gr.  iii  (0.20  Gm.).  This  should  not  be  repeated  more  than  once 
at  an  interval  of  two  hours. 

Aspirin  (acetylsalicylic  acid),  as  being  less  depressing  than  the  coal-tar 
preparations,  is  preferred  by  many  men.  It  is  an  excellent  drug  for  the 
purpose.  The  dose  is  gr.  v  to  gr.  x  (0.33  to  0.66  Gm.)  at  2,  3  or  4-hour 
intervals.  Quinine  has  had  a  similar  usage  and  is  not  infrequently 
combined  with  the  coal-tar  preparations  and  with  the  salicylates,  all  in 
small  doses.  Personally  I  have  not  been  much  impressed  with  the  sup- 
posed synergistic  effects  of  such  combinations  and  have  preferred  to 
learn  the  possibilities  of  a  single  drug  to  becoming  wise  in  the  labyrinth 
of  polypharmacy. 

At  the  beginning  of  the  process  Dover's  powder  .(Pulv.  ipecac  et  opii) 
has  long  been  employed;  sometimes  in  a  full  dose  of  gr.  x  (0.66  Gm.) 
or  in  divided  doses  of  gr.  i-gr.  iiss.  (0.060-0.150  Gm.) .  It  induces  a  mild 
perspiration,  is  an  anodyne  and  an  hypnotic. 

An  ice-bag  applied  to  the  head  may  relieve  the  headache.  The 
circular  ice-bag  is  the  best.  For  technique  of  filling  see  Pneumonia 
Chap.  IX. 

Local  Treatment.  Except  in  the  case  of  children  I  have  not 
been  much  impressed  with  the  efficacy  of  local  measures. 

Cupping.  The  best  plea  for  cupping  is  the  faith  of  the  lay- 
man, yes,  and  of  many  physicians,  the  world  over,  in  the  value  of  the 
cups.  In  my  Bellevue  experience  it  was  the  exception  to  find  a  patient 
brought  in  from  the  East  side  of  New  York,  the  great  immigrant  quarter, 
who,  suffering  from  bronchitis  or  pneumonia,  had  not  been  liberally  and 
well  cupped.  One  must  at  least  be  tolerant  to  long  continued  customs. 
Moreover,  that  the  application  of  the  cup  does  influence  the  circulatory 
states  in  the  chest  would  seem  attested  by  the  sudden  relief  of  pulmonary 
edema  one  sees  occasionally  follow.  For  these  reasons  I  do  not  say  nay, 
if  my  fellow  practitioners  say  yea. 

Counterirritation.  The  form  I  am  accustomed  to  employ  is 
the  mustard  paste  and  this  almost  exclusively  in  children.  However, 
if  the  adult,  who  has  had  bronchitis  and  tracheitis  has  found  comfort 
or  relief  in  mustard  paste  applied  to  the  chest  I  am  quite  willing  to 


ACUTE  BRONCHITIS  AND  TRACHEITIS  105 

indulge  his  preference.  The  strength  should  be  one  part  of  mustard  to 
3,  4  or  5  parts  of  flour,  mixed  with  cold  or  hike-warm  water,  the  strength 
depending  on  the  sensitiveness  of  the  skin.  (For  technique  see  Chap. 
XIV.)  The  mustard  leaf  is  a  more  convenient  form,  but  its  strength 
cannot  be  varied.  (For  technique  of  application  see  Chap.  IX.)  These 
applications  should  not  burn,  but  be  left  on  until  the  skin  is  well  red- 
dened, and  reapplied  at  4  to  6  hour  intervals.  Vaseline  (liquid  pe- 
trolatum) or  olive  oil  is  applied  to  the  skin  in  the  intervals. 

Liniments.  Those  that  are  counterirritants  will  do  no  more, 
if  as  much,  as  mustard,  and  are  decidedly  mussy.  Those  that  are  volatile 
have  another  usage,  locally  applied,  of  which  I  will  speak  presently. 

Poultices.  I  mention  but  to  condemn.  I  doubt  their  thera- 
peutic value  in  the  condition  under  consideration,  while  they  burden 
the  chest  with  an  unnecessary  weight,  leave  the  superficial  vessels 
atonic  and  dilated  and  often  are  left  on  to  become  a  cold,  clammy, 
disagreeable  annoyance. 

Cold.  The  only  way  I  should  care  to  apply  cold  to  the  chest 
in  bronchitis  is  as  a  hydrotherapeutic  measure,  in  the  shape  of  a  cold 
compress.  (For  technique  see  Pneumonia,  Chap.  IX.) 

Inhalations.  These  are  especially  indicated  for  the  laryngitis 
and  tracheitis  and  the  hard  dry  cough  and  substernal  soreness  that 
accompany  these  conditions. 

I  have  long  been  wedded  to  an  "old  wives' "  prescription  for  tracheitis, 
so  common  an  accompaniment  of  a  "cold"  without  further  implication 
of  the  bronchial  tree.  The  ingredients  are  often  found  in  the  household 
or  easily  obtained.  Take  a  tablespoonful  each  of  oil  of  turpentine, 
spirits  of  camphor  and  olive  oil;  mix  them  well  and  sprinkle  liberally 
upon  a  piece  of  flannel,  put  this  on  the  skin  of  the  sternal  region  direct, 
pin  the  flannel  to  the  night  dress  and  leave  on  overnight.  Of  course  a 
prescription  of  equal  parts  of  these  ingredients  may  be  ordered.  The 
volatile  substances  are  inhaled  during  sleep  and  their  soothing  effects 
with  loosening  of  the  expectorations  are  very  manifest  the  next  morning. 
It  does  not  irritate  the  skin  unless  the  patient  has  some  idiosyncracy 
towards  its  ingredients. 

One  of  the  blandest  of  inhalations,  and  to  many  an  agreeable  one, 
is  the  compound  tincture  of  benzoin  3i  or  3ii  (4  c.c.  to  8  c.c.)  of  hot  water 
in  one  of  the  numerous  devices  that  may  be  extemporaneously  devised 
(see  Whooping  Cough,  Chap.  XXII),  or  one  of  the  numerous  croup 
kettles  or  inhalers  on  the  market. 

Such  volatile  substances  as  eucalyptol,  oil  of  pine,  a  teaspoonful  or 
two  in  hot  water  or  a  few  drops  of  a  saturated  alcoholic  solution  of  men- 
thol or  creosote  on  a  dampened  sponge  of  an  inhaler  are  of  value.  These 


106  TREATMENT  OF  ACUTE  INFECTIOUS  DISEASES 

drugs  maybe  combined  as  menthol  1  pt.,  eucalyptol  2  pts.,  and  benzoinol 
3  pts.,  or  menthol,  eucalyptol,  terebene  and  chloroform  equal  parts. 

A  very  excellent  inhalation  is  one  of  equal  parts  of  alcohol,  chloroform 
and  creosote,  (Delafield).  A  few  drops  on  ,a  moistened  sponge  of  a 
Robinson's  inhaler,  or  kindred  device,  a  small  mask  of  perforated  zinc 
over  mouth  and  nose  worn  ad  libitum. 

Cough.  Nothing  controls  cough  better  than  the  morphine  de- 
rivatives of  which  codeine  is  the  best,  because  the  safest  while  at  the  same 
time  effectual.  It  is  usually  prescribed  as  the  phosphate  either  alone  or 
in  combination  with  expectorants;  if  alone  it  may  be  given  in  tablet 
form  or  in  solution,  the  dose  ranging  from  gr.  1/12  to  gr.  %  (0.005  to 
0.015  Gm.)  according  to  the  severity  of  the  process,  which  again  deter- 
mines the  frequency  of  2,  3  or  4  hour  intervals.  Heroine  is  more  depres- 
ant  to  the  respiratory  centre  than  codeine,  but  in  some  instances  decid- 
edly more  potent  to  control  the  cough.  It  is  given  as  the  hydrochloride  in 
the  dose  of  gr.  1/16  to  gr.  1/8  (0.004  to  0.008  Gm.)  and  the  interval  the 
same  as  in  the  case  of  codeine.  In  very  stubborn  cases,  exhausting  the 
patient  and  sacrificing  sleep,  morphine  sulphate  may  be  needed  in 
doses  of  gr.  1/24  to  g.  1/12  (0.0025  to  0.005  Gm.)  at  four-hour  intervals, 
or  exceptionally  it  may  require  an  occasional  hypodermic  injection  of 
gr.  1/8  (0.008  Gm.).  I  have  seen  an  intense  cough  in  bronchitis  accom- 
panying influenza  yield  to  2  per  cent,  cocaine  hydrochloride  as  a  spray 
that  had  bidden  defiance  to  morphine  and  its  derivatives. 

It  must  be  remembered  that  cough  is  a  symptom  of  purposeful  signif- 
icance, as  most  symptoms  are,  and  that  its  purpose  is  to  expel  secretions 
laden  with  infecting  organisms.  For  this  reason  cough  that  accomplishes 
this  end,  should  be  left  alone;  it  is  the  dry,  racking,  exhausting  cough 
that  requires  interference. 

Expectorants.  I  suspect  that  my  usage  of  expectorants  has 
been  based  rather  on  unreasoning  reverence  for  hoary  tradition  than  on 
conviction  of  their  therapeutic  value.  Depressant,  sedative  or  nauseat- 
ing expectorants,  such  as  ipecac,  tartar  emetic,  apomorphine  and  potas- 
sium salts  were  supposed  to  be  indicated  in  the  early  stages  and  stimu- 
lating expectorants,  the  ammonium  salts  in  the  later  stages.  An  example 
of  the  former  is  the  Brown  mixture  (Mistura  Glycyrrhizse  Comp.) 
which  contains  an timony  and  is  ordered  in  doses  of  5ss.  in  water  every 
four  hours.  In  spite  of  indications  signified  above  it  is  often  used  as  a 
vehicle  for  simulating  expectorants  (see  below) ;  another  example  is : 

Q 

Syrupi  Ipecacuanhse 5  vi  (24 . 00) 

Potassii  Citratis 3iii  (12.00) 

Aqua  q.  s.  ad giv  (120.00) 


ACUTE  BRONCHITIS  AND  TRACHEITIS  107 

M. 

S.    A  dessertspoonful  (3ii  or  8  c.c.)  every  4  hours. 

As  examples  of  the  stimulating  expectorants: 


Ammonii  Chloridi  ...................  5iss.-5iiss.  (6-10) 

Codeinse  Phosphatis  .....  ............  gr.  iv  (0.25) 

Syrupi  Tolutani  .....................  5ii  (30.00) 

Aquae  q.  s.  ad  .......................  5iv  (120.00) 

M.  et  S.  5i  every  3-^  hours  in  water. 

If  the  cough  is  not  annoying  the  codeine  may  be  left  out.    Another 
such  prescription  is  as  follows  : 

ft 

Ammonii  Chloridi  ................  gr.  xxxvi-5i        (2.40-4  c.c.) 

Misturse  Glycyrrhizse  Comp  ........  3  vi  (180  c.c.) 

M.  et  S.  5ss.  (i  tablespoonful)  every  4  hours. 

In  no  type  of  prescription  has  more  ingenuity  of  combinations  been 
exercised  than  in  expectorant  mixtures  with  the  result  that  the  patient 
suffers  from  the  physician's  transference  of  affections  from  one  alluring 
prescription  to  another. 

Children  should  be  put  to  bed  in  a  room  with  the  tempera- 
ture at  70°  F.  Counter-irritation  in  the  shape  of  mustard  paste,  one  part 
of  mustard  to  six  parts  of  flour  in  infants,  one  to  five  or  four  in  older 
children,  I  believe  to  be  of  more  value  than  in  adults.  It  should  be 
applied  all  over  the  chest,  left  on  until  the  skin  is  slightly  reddened  and 
reapplied  once  in  four  to  six  hours.  Liquid  petrolatum  or  olive  oil  being 
applied  in  the  interval. 

Do  not  use  poultices  and  pneumonia  jackets. 

Inhalations.  Compound  tincture  of  benzoin  is  the  best.  Creo- 
sote too  may  be  tried.  (See  Whooping  Cough,  Chap.  XXII,  for  details.) 

Expectorants  should  be  used  sparingly  in  children  and  in  infants 
and  young  children  not  at  all.  In  older  children  in  the  early  stages 
ipecac  and  antimony  may  be  used  and  that  especially  when  there  is 
spasmodic  tendency  in  the  larynx  or  bronchi.  One  may  use  tablets  of 
ipecac  and  tartar  emetic  each  gr.  1/100  (0.0006  Gm.)  at  2  to  4  hour 
intervals.  In  later  stages  with  a  view  to  stimulating  expectoration 
ammonium  chloride  gr.  i  to  gr.  iii  (0.060-0.20  Gm.)  in  Brown  mixture 
5i  to  5ii  (4-8  c.c.)  may  be  used  at  3  to  4  hour  intervals.  Children  are 
much  more  prone  to  bronchial  spasm  as  they  are  more  prone  to  croup 
than  adults  when  they  suffer  from  a  catarrhal  inflammation.  Sedatives, 
such  as  the  tartar  emetic  and  ipecac  or  small  doses  of  antipyrin  and 


108          TREATMENT  OF  ACUTE  INFECTIOUS  DISEASES 

sodium  bromide,  say  antipyrin  gr.  i  (0.060  Gm.)  to  sodium  bromide  gr. 
iii  (0.20  Gm.)  at  4  hour  intervals  lessen  this  tendency,  but  if  an 
asthmatic  attack  does  occur  adrenalin  (epinephrin)  intramuscularly  in 
doses  of  m.  ii-m.  v  (0.130-3  c.c.)  is  most  effectual  to  afford  relief. 

A  preparation  often  used  is  the  Elixir  Terpini  Hydratis  cum  Heroina 
of  the  national  formulary.  It  contains  in  each  dram  (4  c.c.)  1  grain 
(0.06  Gm.)  of  terpin  hydrate  and  1/24  grain  of  heroine. 

Young  children  prone  to  have  colds  should  have  diseased  tonsillar 
and  adenoid  tissues  removed.  Their  sleeping  room  should  not  be  too 
cold,  not  below  60°  F.,  the  skin  should  be  hardened  by  gradually  accus- 
toming it  to  the  cold  bath.  Underclothing  should  contain  woolen,  but 
be  light  of  weight.  Overclothing  in  the  house  is  pernicious.  Sufficient 
extra  clothing  is  added  when  exposed  to  cold.  Damp  or  wet  stockings 
or  clothing  should  be  promptly  changed. 

These  same  prophylactic  measures  obtain  for  adults,  attention 
to  abnormalities  in  the  upper  air  passages,  cold  baths,  open  air  exercise, 
regulation  of  clothing,  avoiding  exposure  to  damp  cold.  In  some  in- 
stances the  recovery  of  a  suspicious  organism  from  the  sputum  during 
the  acute  attack  may  be  utilized  for  the  production  of  a  vaccine  to  be 
used  prophylactically  between  the  attacks. 

SUMMARY 

Treatment. 

Confine  to  house  and,  if  any  fever,  to  bed  for  three  days  after  tem- 
perature is  normal. 

Room. 

Chosen  with  regard  to  light  and  sun  and  nearness  to  bath  room. 
No  smoking  allowed. 
Talking  to  be  discouraged. 

Diet. 

Unless  severe  no  special  directions  required. 

If  severe,  treat  as  in  pneumonia.    (See  Chap.  IX.) 

Precautions. 

Isolate  patient  from  all  but  those  acting  as  nurse. 

The  secretions  from  mouth,  nose  and  eyes  convey  the  infection  and 

the  patient  should  be  instructed  to  cover  the  mouth  and  nose  when 

coughing  or  sneezing  with  gauze  or  old  cloths,  which  should  be 

placed  in  paper  bags  and  burned. 

All  linen  should  be  immersed  in  water  until  it  can  be  boiled. 
Boil  all  table  utensils  and  keep  separate. 
Separate  thermometer  used  and  kept  immersed  in  an  antiseptic 

solution  (phenol  1:20). 


ACUTE  BRONCHITIS  AND  TRACHEITIS  109 

Early  measures. 

Hot  bath,  hot  drinks,  etc.,  as  summarized  under  Acute  Rhinitis, 

Chap.  IV. 
Bowels. 

Mild  saline  such  as  Hunyadi  or  liquor  magnesii  citratis  Bviii  (240 
c.c.)  or  Epsom,  Rochelle  or  Glauber's  salt,  3ii-iv  (8-15  Gm.). 

Aches  and  pains. 
9 

Acetanilidi 1 .50        (gr.  xxiiss.) 

Sodii  Bicarbonatis 1 .00        (gr.  xv) 

Caffeinae  Citratse 0.50        (gr.  viiss.) 

M.  et  div.  in  cap.  no.  xv. 

S.   One  every  half  hour  for  4  doses,  then  every  hour  for  4  doses  and 
then  every  two  hours  for  first  24  hours. 

Or  acetphenetidin  (phenacetin)  in  three  grain  doses  (0.20  Gm.)  or 

combine  with  sodium  bicarbonate  and  citrated  caffeine  in  doses 

given  above. 
Or  antipyrin  grains  two  (0.120  Gm.)  may  be  given  in  solution,  or  if 

headache  is  severe  single  large  doses  of  acetphenetidin,  gr.  x  (0.66 

Gm.)  with  citrated  caffeine  gr.  iii  (0.20  Gm.)  and  repeat  once  after 

two  hours  if  necessary. 
Aspirin  (acetylsalicylic  acid)  gr.  v-x  (0.33-0.66  Gm.)  at  2,  3,  or  4 

hour  intervals. 
Dover's  powder  (Pulv.  ipecac  et  opii)  gr.  x  (0.66  Gm.)  or  in  divided 

doses  of  gr.  i-ii  ss.  (0.60-0.150  Gm.). 
Ice  bag  to  head. 
(See  Typhoid  Fever,  Chap.  XIV.) 

Local  treatment. 

Cupping.    (See  Pneumonia,  Chap.  IX.) 
Counterirrit  ation . 

Mustard  paste  (1  part  mustard  to  3,  4  or  5  parts  flour  mixed  with 

luke  warm  water).    (For  technique  see  Pneumonia,  Chap.  IX.) 
Cold  Compress. 

(See  Pneumonia,  Chap.  IX.) 
Ice  collar. 

(See  text.) 
Hot  fomentations. 

(See  text.) 
Inhalations. 

(See  Acute  Rhinitis,  Chap.  IV.) 

Flannel  wet  with  equal  parts  of  oil  of  turpentine,  spirits  of  cam- 
phor and  olive  oil.    Lay  on  chest  and  pin  hi  the  night  dress  and 
inhale  the  vapor. 
Compound  tincture  of  benzoin  or  eucalyptol  or  oil  of  pine  3i  (4  c.c.) 

in  boiling  water,  or 

A  few  drops  of  a  saturated  alcoholic  solution  of  menthol  or, 
Creosote  on  a  dampened  sponge  of  an  inhaler  or, 


110          TREATMENT  OF  ACUTE  INFECTIOUS  DISEASES 

Combine  menthol,  1  part,  eucalyptol,  2  parts,  and  benzoinol,  3  parts 

or, 

Menthol,  eucalyptol  and  chloroform  equal  parts  or, 
Equal  parts  of  alcohol,  chloroform,  and  creosote.    (Delafield.) 
Put  a  few  drops  of  any  of  these  on  a  moistened  sponge  of  a  Robin- 
son inhaler  or  kindred  device  and  wear  over  nose  and  mouth 
ad  libitum. 

Cough. 

Codeine  phosphate  gr.  1/12  to  gr.  Y±  (0.005-0.015  Gm.)  every  2,  3  or 
4  hours  according  to  the  severity. 

Heroine  hydrochloride  gr.  1/16-1/8  (0.004-0.008  Gm.)  every  2,  3  or 
4  hours. 

Morphine  sulphate  gr.  1/24-1/12  (0.0025-0.005  Gm.)  at  four-hour  in- 
tervals if  the  above  is  not  efficacious.  Give  gr.  1/8  hypodermically 
if  necessary  to  effect  sleep. 

Cocaine  hydrochloride  solution,  2  per  cent.,  used  as  a  spray  may 
relieve  a  stubborn  cough.  Use  two  or  three  jets  every  two  to  four 
hours.  Have  patient  expectorate  excess  after  spraying. 

Expectorants. 
Brown  mixture  5  ss.  in  water  every  4  hours  or, 

* 

Syrupi  Tolutani 5ii  (30.00) 

Aquse  q.  s.  ad 5iv          (120.00) 

M.  et  S.  3i  every  3-4  hours  in  water. 

S 

Syrupi  Ipecacuanhas 3vi  (20.00) 

Potassii  Citratis 3iii  (10.00) 

Aquae  q.  s.  ad.. . 5iv  (120.00) 

M.  et  S.  a  dessertspoonful  (3ii-8  c.c.)  every  four  hours. 

3 

Ammonii  Chloridi gr.  xxxvi-3i  (2.40-4  c.c.) 

Misturae  Glycyrrhizae  Comp 3  vi  (180  c.c.) 

M.  et  S.  5  ss.  (1  teaspoonful)  every  4  hours. 

Children. 

To  bed  in  room  at  temperature  of  70°  F. 
Mustard  paste  one  part  mustard  to  one  to  six  parts  of  flour. 
For  technique  see  Pneumonia.    (See  text.) 

Inhalations. 

Compound  tincture  of  benzoin  on  water  or  creosote.  (See  above  and 
Whooping  Cough,  Chap.  XXII.) 

Expectorants. 

Do  not  use  in  infants  and  young  children. 

For  older  children  with  spasmodic  tendency  use  tablets  of  ipecac 

and  tartar  emetic  gr.  1/100  (0.0006  Gm.)  of  each  every  2  to  4  hours. 
Later  stages  use  ammonium  chloride  gr.  i  to  iii  (0.06-0.20  Gm.)  in 

Brown  mixture  3i-3ii  (4-8  c.c.)  every  3  to  4  hours. 


ACUTE  BRONCHITIS  AND  TRACHEITIS  111 

Or,  antipyrin  gr.  i  (0.060  Gm.)  and  sodium  bromide  gr.  iii  (0.20  Gm.) 
every  4  hours  to  lessen  tendency  to  bronchial  spasm. 

For  asthmatic  attack  give  adrenalin  (epinephrin)  1:1000  intra- 
muscularly in  doses  of  m.  ii-v  (0.130-3  c.c.). 

Prophylaxis. 

Removal  of  diseased  tonsilar  and  adenoid  tissue. 
Current  deformities  in  upper  air  passages. 
Sleeping  room  not  too  cold,  not  below  60°  F. 
Cold  baths  or  sponges. 

Underclothes  to  contain  wool  and  be  of  light  weight. 
Add  sufficient  extra  clothing  on  going  out  of  doors. 
Change  damp  or  wet  clothing  promptly. 

If  pathogenic  organism  can  be  isolated  make  a  vaccine  to  be  used 
between  attacks. 


CHAPTER  VJII 

PLEURISY  (PLEURITIS) 

PLEUKISY  or  pleuritis  as  the  latter  name  implies  is  an  inflammation 
of  the  pleura,  characterized  by  the  usual  phenomena  of  congestion  and 
the  exudation  of  fibrin,  serums  and  the  cellular  constituents  of  the 
blood,  diapedesis  and  emigration. 

When  the  exudate  is  largely  fibrinous  the  process  is  called  a  fibrinous 
or  plastic  pleurisy  or  in  less  technical  parlance  a  "dry  pleurisy. " 
When  the  exudation  of  serum  predominates  the  process  is  called  a 
serous  or  serofibrinous  pleurisy,  as  the  amount  of  fibrin  in  the  exu- 
date is  small  or  more  abundant.  It  is  commonly  termed  a  "pleurisy 
with  effusion. "  When  the  emigration  of  white  blood  cells  is  the  domi- 
nant feature  it  is  called  a  purulent  pleurisy  or  an  empyema. 

Pleurisies  may  be  primary  or  secondary.  Nearly  all  pleurisies  are 
secondary,  originating  from  processes  starting  in  the  lung,  pericardium, 
mediastinum,  liver,  or  brought  by  the  blood  stream.  So-called  primary 
pleurisies,  especially  those  characterized  by  an  exudation  of  serum, 
are  in  the  vast  majority  of  cases  tubercular  in  origin.  The  other  organ- 
isms responsible  for  pleurisy  are  in  the  main  pneumococcus  and  strep- 
tococcus. Other  bacteria  than  these  play  a  very  minor  role.  The  end 
results  of  pleurisies  are  resolution  to  a  normal  condition  or  commonly 
proliferation  with  adhesions  or  more  complete  organization  with  partial 
or  complete  obliteration  of  the  pleural  sac. 

Fibrinous  Pleurisy  is  the  least  serious  of  the  types,  both  as  to 
its  course,  inconveniencies  and  sequences.  It  must  not  be  forgotten 
in  any  case,  even  of  dry  pleurisy,  that  the  cause  in  the  vast  majority 
of  cases  of  "primary  pleurisy"  is  tuberculosis,  and  every  effort  should 
be  made  to  determine  its  presence  or  absence.  Whether  exposure  to 
cold  alone  in  the  absence  of  an  infecting  organism  can  cause  fibrinous 
pleurisy  is  open  to  serious  doubt;  and  yet  this  is  often  offered  as  an 
adequate  explanation. 

As  has  been  said,  the  secondary  cases  arise  from  infections  in  the 
lung,  pericardium,  and  mediastinum,  and  also  from  the  peritoneum, 
wounds  in  the  chest  walls  and  in  the  course  of  cardio-renal  disease. 
The  symptoms  are  superadded  to  those  of  the  disease  to  which  the 
pleurisy  is  secondary,  but  in  primary  cases  the  dry  pleurisies  are  not  as 
severe  as  the  forms  with  effusion. 


PLEURISY  (PLEURITIS)  113 

Pain  is  the  most  characteristic  symptom,  most  commonly  felt  in 
the  axilla  or  in  the  mammary  regions;  more  rarely  in  the  back.  Espe- 
cially is  it  to  be  remembered  that  diaphragmatic  pleurisy  is  full  of  pitfalls 
and  gins  for  the  unwary;  for  an  involvement  of  the  central  part  of  that 
structure  gives  rise  to  pain  in  the  shoulder  and  trapezius  muscle  with 
tenderness  of  the  trapezius  ridge,  brought  about  by  reflexes  through 
the  phrenic  and  fourth  cervical,  while  the  peripheral  portion  causes  pain 
in  the  lower  costal  region,  the  lumbar  region  and  abdomen.  The  muscles 
of  the  abdomen  may  be  rigid  and  painful  to  palpation.  As  no  friction 
rub  may  be  heard,  diagnoses  referable  to  the  kidney,  gall-bladder,  ap- 
pendix and  other  structures  are  frequent  enough. 

Constitutional  symptoms  as  a  rule  are  not  marked,  the  temperature, 
at  the  most,  trivial.  Some  malaise  may  be  experienced. 

C  ough  occurs  in  most  cases,  whether  due  to  the  affected  pleura  or  to 
an  infected  lung  is  a  question.  Severe  pain  on  breathing  may  cause 
shallow,  rapid  breathing,  with  some  dyspnoea.  The  classical  physical 
sign  is  the  friction  sound — commonly  a  crepitant  or  subcrepitant  rale — 
more  rarely  a  coarse  rub  or  a  sound  like  a  mucous  rale.  Change  in 
percussion  with  dulness  occurs  even  when  the  fibrin  is  very  abundant. 
The  leucocytic  count  is  usually  slightly  increased — 12,000  to  20,000. 

Treatment.  In  the  milder  forms  the  patient  may  be  allowed  out 
of  bed,  but  should  be  confined  to  the  house.  If  there  is  any  elevation  of 
temperature  he  should  be  put  to  bed.  In  severe  attacks  the  patient  will 
require  no  urging  to  remain  in  bed.  Here  he  will  commonly  be  found 
lying  on  the  affected  side  in  the  unconscious  effort  to  splint  that  side, 
as  by  so  limiting  the  respiratory  excursion  he  lessens  the  pain  incident 
upon  the  movement  of  the  pleural  surfaces  upon  each  other.  This  very 
fact  gives  us  a  hint  as  to  proper  procedure,  as  will  be  detailed  below. 

For  the  choice  of  a  room  with  reference  to  light  and  air  the  reader 
is  referred  to  the  article  on  pneumonia;  but  emphasis  must  be  laid  on 
the  open  air  treatment  because  the  case,  if  a  primary  one,  is  in  all  prob- 
ability tuberculous.  The  same  rules  as  are  laid  down  in  standard  trea- 
tises on  tuberculosis  are  applicable  in  these  cases;  in  brief,  they  are  open 
air  day  and  night  with  proper  attention  to  shelter  against  high  winds, 
dust  clouds  and  inclement  weather.  If  proper  care  cannot  be  given 
at  home  or  if  the  patient  so  prefers,  sanitarium  treatment  should  be 
sought. 

Diet.  In  febrile  cases  the  diet  is  like  that  of  other  acute  infectious  dis- 
eases—see Chap.  II;  Pneumonia,  Chap.  IX;  Typhoid  Fever,  Chap.  XIV. 
If  there  is  no  fever  the  diet  should  be  liberal;  such  as  we  would  offer  to  a 
tuberculous  patient,  milk,  eggs,  cereals,  breadstuffs,  meat  and  vegetable 
soups  and  some  meat,  fish,  fowl,  and  vegetables,  fruits  and  light  desserts. 


114  TREATMENT  OF  ACUTE  INFECTIOUS  DISEASES 

Drinks.  Water,  and  fruit  juices  may  be  given  ad  libitum.  Cocoa 
may  be  allowed,  very  weak  tea,  and  milk  may  be  flavored  with  coffee. 

Bowels.  The  bowels  should  be  moved  when  the  patient  is  first 
seen.  One  may  give  castor  oil  or  calomel  followed  by  saline  or  salines 
alone.  The  calomel  may  be  given  in  a  single  dose  of  gr.  ii-iii  (0.120-0.2 
Gm.)  or  as  I  prefer  in  %  gram  (0.015  Gm.)  doses  at  quarter-hour  inter- 
vals for  six  doses.  I  fancy  this  lesser  total  so  given  is  as  effectual  as  the 
larger  doses  given  at  once.  One  follows  the  calomel  in  4  to  6  hours,  or  if 
the  calomel  is  given  at  night,  the  next  morning,  by  salts.  One  may  use 
Rochelle,  Epsom,  or  Glauber's  salt  in  3/4  to  one  glass  of  water.  Or 
milder  salines  may  be  used  such  as  the  solution  of  magnesium  citrate 
8-12  ounces  or  a  Seidlitz  powder  or  one  of  the  many  saline  laxatives  on 
the  market,  of  which  Hunyadi  water  is  a  type.  If  a  satisfactory  move- 
ment does  not  follow  each  day  or  the  stools  are  foul  or  otherwise  abnor- 
mal, an  enema  may  be  given  every  other  day,  or  one  of  the  milder  salines. 
If  the  condition  of  the  stools  seems  to  demand  it  colonic  irrigations  may 
be  given.  The  physician  should  have  some  accurate  knowledge  of  the 
state  of  the  patient's  bowels  in  every  acute  disease;  but  I  am  not  sure 
that  routine  catharsis,  even  as  described  above,  may  not  be  too  drastic. 
The  object  really  should  be  to  secure  good  movements  with  the  least 
and  gentlest  assistance  possible. 

Local  Measures.  These  have  been  applied  for  a  double  purpose; 
to  exert  a  modifying  influence  on  the  inflammatory  process  in  the  pleura 
and  to  afford  relief  from  pain;  one  may  argue  about  the  possibility  or 
probability  of  attaining  the  first  end  arrived  at;  but  certainly  some  of 
these  local  measures  do  relieve  pain.  One  of  the  most  effectual  of  these 
is  strapping  the  chest. 

Strapping  the  Chest.  This  manuoevre  accomplishes  what  na- 
ture is  trying  to  do,  namely,  to  splint  the  chest  as  explained  above.  The 
technique  is  as  follows.  One  uses  zinc  oxide  adhesive  plaster,  the  well- 
known  surgeons'  adhesive.  The  strip  must  be  wide  enough  to  extend 
from  the  axilla  to  the  edge  of  the  ribs,  about  5  inches  in  the  adult  and 
long  enough  to  encircle  the  affected  side,  overlapping  the  opposite  chest 
some  3  inches  both  in  front  and  behind.  The  patient,  if  he  is  able  to  be 
out  of  bed,  stands  before  the  operator,  who  holds  the  sheet  of  adhesive 
stretched  and  smooth  as  he  faces  the  patient's  affected  side;  one  end  of 
the  strip  is  applied  some  3  inches  to  the  unaffected  side  of  the  patient's 
spinous  processes  and  firmly  secured ;  the  patient  is  then  asked  to  breathe 
out  as  completely  as  possible  and  during  his  continued  expiratory 
phase  to  turn  his  body  slowly  to  face  the  operator  who  smoothly 
applies  the  taut  adhesive  strip  as  he  turns,  overlapping  the  opposite  side 
in  front. 


PLEURISY  (PLEURITIS)  115 

Thus  applied  during  expiration  the  motion  of  the  affected  chest  is 
greatly  restricted  and  the  relief  immediate. 

If  it  is  not  wise  to  have  the  patient  out  of  bed,  he  may  sit  up  in  bed 
and  the  technique  described  is  imitated  as  best  possible  under  the  cir- 
cumstances. 

When  the  patient  is  very  stout,  and  in  women  with  large  breasts,  the 
application  of  the  adhesive  in  a  single  sheet  cannot  be  smoothly  made. 
One  uses  in  these  cases  three  or  four  strips  which  overlap  each  other 
and  conform  more  readily  to  the  contour  of  the  chest.  If  the  chest  is 
hairy,  it  should  be  shaven  before  the  plaster  is  applied.  This  facilitates 
its  removal  when  the  time  comes.  It  may  be  pulled  off  by  a  sudden 
strong  jerk  or  if  there  is  much  hair  or  the  patient  fearful,  it  may  be 
softened  before  removal  by  benzine  or  ether.  If  strapping  cannot  be 
obtained,  a  snug  binder  or  towel  may  be  tried  as  a  substitute.  If  the 
strapping  is  not  comfortable  or  if  for  any  reason  it  does  not  seem  feasible 
to  apply  it,  the  application  of  cold  is  usually  found  gratifying. 

The  Ice  Bag.  Perhaps  the  best  method  of  applying  cold  is  by 
the  ice  bag.  The  circular  ice  bag  with  a  metallic  cup  is  the  one  I  prefer. 
The  ice  should  be  cracked  to  the  size  of  the  end  of  one's  thumb  and 
enough  put  into  the  bag  to  cover  the  bottom.  Only  enough  water  is 
added  to  cover  the  ice;  the  air  is  then  expressed  and  the  metallic  cap 
screwed  on.  This  affords  a  pliable  bag,  which  one  filled  with  air  does 
not,  and  clings  closely  to  the  underlying  surface.  A  layer  or  two  of  linen 
is  put  over  the  bag  to  intervene  between  it  and  the  skin  and  the  whole 
secured  to  the  chest  by  a  towel  or  binder.  The  bag  should  be  taken  off 
at  intervals  of  two  or  three  hours,  lest  too  long  continuous  application 
damage  the  tissues.  When  the  bag  is  taken  off,  one  should  apply  oil  or 
vaseline  to  the  skin.  The  use  of  salt  in  the  bag  is  to  be  deprecated.  As 
our  chief  aim  in  making  use  of  these  local  measures  is  to  afford  comfort, 
if  cold  fails  to  afford  it,  one  may  try  heat. 

Heat.  Hot  water  bag.  This  is  an  article  rarely  wanting  in  a 
household  and,  of  course,  readily  applied.  One  or  two  directions,  how- 
ever, will  not  be  out  of  place.  Only  partially  fill  the  bag  with  hot  water 
and  by  squeezing  it,  expel  the  air  and  screw  in  the  plug  to  render  the  bag 
flaccid  and  pliable;  place  flannel  between  bag  and  skin  to  prevent  burn- 
ing it;  keep  in  place  by  a  binder. 

Electric  Pad.  This  clever  device,  that  may  be  utilized  in  any 
modern  dwelling  house  of  city  or  town,  furnished  with  current,  is  most 
easy  of  application — light,  dry  and  easily  regulated  to  the  desired  tem- 
perature. 

Fomentations.  For  the  technique,  see  Pneumonia,  Chap.  IX. 
Smear  the  skin  with  oil  or  vaseline  before  applying  and  cover  with  a  dry 


116  TREATMENT  OF  ACUTE  INFECTIOUS  DISEASES 

flannel  to  retain  the  heat.  These  are  removed  as  fast  as  they  become 
cool.  A  series  of  these  are  applied  at  intervals,  dry  flannel  being  put  in 
their  place  in  the  meantime.  The  disadvantage  of  fomentations  lies 
in  the  necessity  of  continual  renewal.  One  may  get  a  more  continuous 
effect  by  the  hot  poultice. 

Poultice.  For  technique,  see  Pneumonia,  Chap.  IX.  A  poultice 
will  keep  its  heat,  when  properly  made,  about  an  hour.  When  it  is 
removed  a  dry  flannel  is  put  over  the  site  previously  smeared  with  olive 
oil  or  vaseline.  Huge,  heavy  poultices,  and  such,  allowed  to  remain  on 
long  after  they  have  become  cold  are  not  only  useless  but  harmful. 
Another  time-honored  local  measure  is  count erirritation. 

Counterirritants.  Perhaps  the  simplest,  most  easily  applied 
and  one  almost  always  to  be  found  in  any  household  is  mustard.  When 
mustard  is  at  hand  the  paste  is  the  best  form  in  which  to  apply  it.  Its 
strength  can  be  readily  regulated  by  the  proportion  of  flour  and  mus- 
tard used,  and  its  preparation  is  of  the  easiest.  When  a  paste  cannot  be 
conveniently  prepared  the  mustard  leaf  (charta  sinapis),  is  readily 
obtainable  and  simple  of  application.  For  the  technique  of  preparation 
and  application  of  the  mustard  leaf  and  mustard  paste,  see  Pneumonia, 
Chap.  IX. 

The  mustard  is  to  be  left  on  until  the  skin  is  well  reddened  and  when 
removed,  the  skin  is  to  be  washed  with  soap  and  water  to  free  it  from 
any  little  particles  of  mustard  adhering  and  then  smeared  with  a  thin 
coat  of  vaseline  or  sweet  oil.  The  applications  should  be  repeated  at 
four-hour  intervals  or  even  three-hour  intervals,  if  the  physician  hopes  to 
influence  the  pathological  processes;  if  relief  of  pain  alone  is  aimed  at, 
the  number  and  frequency  of  the  application  depends  on  results. 

Iodine.  The  tincture  has  been  used  as  a  counterirritant.  It  offers 
no  advantages  over  mustard;  it  is  less  easily  regulated  and  more  likely 
to  set  up  a  disagreeable  dermatitis. 

The  Cautery.  Either  the  acutal  cautery  or  the  electro-cautery 
offers  certain  advantages  as  a  counterirritant.  The  cautery  makes  a 
more  decided  impression  on  the  sensory  nerves  than  the  mustard  and 
may  relieve  pain  when  mustard  fails.  It  is  flicked  lightly  over  the  area  of 
pain,  just  reddening  the  skin  or  at  the  most  inducing  a  very  slight  blister. 
The  part  is  then  treated  to  a  coat  of  vaseline,  or  sweet  oil,  and  covered 
with  a  layer  of  gauze.  The  procedure  is  easy,  it  is  neat,  and  contrary  to 
the  patient's  anticipations  of  an  ordeal  by  fire,  being  provocative  of  but 
little  pain  in  the  application. 

Blisters.  Blisters  at  one  time  in  much  vogue  have  fallen  largely 
into  disuse.  I  do  not  think  that  they  effect  any  more  than  the  measure 
just  described;  on  the  other  hand  the  site  of  their  application  is  often 


PLEURISY  (PLEURITIS)  117 

sore  and  may  leave  a  sore  surface,  necessitating  protective  dressings  and 
adding  discomfort  rather  than  comfort  to  the  patient. 

For  the  technique  of  applying  blisters  see  Rheumatism,  Chap.  III. 
Another  local  measure  still  much  in  use  among  the  laity,  especially 
among  our  recent  European  immigrants,  is  cupping.  In  my  service  at 
Bellevue  Hospital  it  is  the  exception  to  find  a  patient  drawn  from  the 
great  East  side,  who  is  admitted  for  pneumonia  or  pleurisy,  who  has  not 
been  thoroughly  and  well  cupped.  This  cupping  may  have  been  done  by 
a  physician  or  by  a  lay  hand.  The  rationale  of  the  procedure  rests  only 
on  theory  and  but  little  definite  knowledge.  It  may  modify  the  distri- 
bution of  blood  in  the  inflamed  pleura  as  is  claimed  for  it,  but  it  is  at  best 
a  dubious  assumption  or  it  may  operate  through  the  nerve  reflexes.  The 
best  results  seem  to  follow  the  early  application  of  cups  in  early  and 
sudden  attacks. 

For  technique  of  cupping  see  Pneumonia,  Chap.  IX. 

Wet  cups  and  leeches  have  been  used  to  effect  the  same  purpose, 
but  are  not  to  be  recommended. 

Drugs.  For  relief  of  pain.  If  the  local  measures  are  not  successful, 
one  must  have  recourse  to  drugs. 

When  the  pleurisy  is  a  part  of  a  rheumatic  attack,  salicylates  are 
indicated,  or  as  salicylate  therapy  will  have  been  instituted  already, 
they  are  to  be  continued.  A  pleurisy  may  occur  as  an  early  rheumatic 
manifestation  or  accompany  some  other  particular  manifestation  of 
rheumatism;  for  example,  tonsillitis,  or  in  a  rheumatic  subject  with- 
out other  expressions  of  the  infection,  and  in  such  cases  salicylates 
should  be  administered  as  in  rheumatism.  For  details  see  Acute  Rheu- 
matic Fever,  Chap.  III.  However,  the  practitioner  must  keep  in  mind 
the  far  more  common  cause,  tuberculosis,  which  may  well  occur  in  a 
patient  who  has  had  rheumatism.  As  I  write  a  young  man  with  a 
marked  mitral  stenosis  from  a  previous  attack  of  rheumatism  just 
developed  a  fibrinous  pleurisy  without  other  rheumatic  symptoms; 
but  an  X-ray  picture  of  the  chest  shows  two  old  healed  tubercular 
lesions  of  the  lung  and  emphasizes  the  necessity  for  caution  in  these 
cases.  From  whatever  origin,  the  pain  of  pleurisy  may  be  relieved  by 
the  use  of  the  salicylates.  My  preference  is  the  acetylsalicylic  acid 
(aspirin)  in  doses  of  gr.  x  (0.66  Gm.)  every  two  or  three  hours  until  its 
value  is  demonstrated  or  its  failure  calls  for  its  interruption.  Sodium 
salicylate  in  doses  of  gr.  x-xv  (0.66-1  Gm.)  at  the  same  intervals  may 
be  used.  This  may  be  given  with  bicarbonate  of  soda,  two  grains  of  the 
latter  to  one  of  the  salicylate,  or  given  alone. 

For  the  use  of  the  various  forms  of  the  salicylates  and  prescriptions  of 
the  same  see  Acute  Rheumatic  Fever,  Chap.  III. 


118  TREATMENT  OF  ACUTE  INFECTIOUS  DISEASES 

The  salicylates  have  the  advantage  of  being  the  least  harmful  of  the 
anodynes. 

Coal-Tar  Preparations.  When  the  circulation  is  in  any  degree 
imperilled,  these  should  not  be  used;  but  in  a  primary  pleurisy  circula- 
tory embarrassment  is  very  rare.  The  coal-tar  preparations  may  be 
used  then  with  safety  in  reasonable  doses.  I  should  prefer  to  use  them 
only  when  the  salicylates  fail  or  when  for  some  reason,  such  as  an  idio- 
syncracy  or  gastric  distress,  the  salicylates  may  not  be  used. 

If  the  pain  is  severe  it  may  be  necessary  to  use  a  single  large  dose  of 
phenacetin  (acetphenetidin)  gr.  xv  (1  Gm.)  or  of  antipyrin  gr.  viiss. 
(0.5  Gm.)  or  of  acetanilid  gr.  v  (0.33  Gm.) ;  but  as  a  rule  I  believe  better 
results  follow  smaller  doses  frequently  repeated,  e.  g.,  phenacetin  gr.  iii 
(0.2  Gm.)  or  acetanilid  gr.  iss.  (0.10  Gm.)  with  which  one  may  combine, 
if  he  so  chooses,  a  grain  (0.06  Gm.)  of  sodium  bicarbonate  and  a  half 
grain  (0.030  Gm.)  of  citrated  caffeine.  Antipyrin,  which  has  the  advan- 
tage of  being  soluble  in  water,  can  be  given  in  gr.  ii  (0.120  Gm.)  doses. 
These  doses  may  be  repeated  at  first  at  J4  to  Yi  hour  intervals,  depend- 
ing on  the  severity  of  the  pain,  for  four  doses,  then  at  hourly  intervals 
for  the  same  number  (4),  and  then  every  two  hours. 

If  the  pain  does  not  yield  to  these  drugs  one  should  have  recourse  to 
codeine  phosphate  in  doses  of  gr.  1/8  to  gr.  1/2  (0.008-0.03  Gm.)  hypo- 
dermically  or  better  intramuscularly. 

If,  as  may  well  happen,  codeine  fails  to  afford  relief,  one  must  have 
recourse  to  morphine  given  as  the  sulphate  intramuscularly,  in  doses  of 
gr.  1/8  to  gr.  Y±  (0.008-0.015  Gm.). 

Cough.  DyspiKea.  Both  these  symptoms  in  an  uncomplicated 
pleurisy  are  due  to  the  painful  act  of  breathing  and  are  to  be  treated  in 
the  same  manner  as,  or  rather,  are  being  treated  simultaneously  with 
the  pain. 

With  the  disappearance  of  symptoms  which  in  some  instances  may 
be  fairly  prompt,  our  obligations  to  the  patient  does  not  come  to  an  end. 

The  patient  in  all  primary  cases  as  has  been  said,  is  a  tuberculosis 
suspect.  If  no  pulmonary  signs  have  at  any  time  been  detected,  then  the 
patient  should  be  treated  as  tuberculous,  in  a  sanatorium  if  possible,  or 
if  not,  at  home,  until  we  can  be  sure  that  quiescence  of  the  lesion  has  been 
obtained. 

PLEURISY  WITH  EFFUSION 

A  primary  pleurisy  with  effusion  is  almost  certainly  tuberculous, 
though,  occurring  in  a  rheumatic  subject,  it  may  be  the  first  expression 
of  a  reinfection.  The  constitutional  symptoms  are  as  a  rule  more  marked 
and  the  course  more  prolonged. 


PLEURISY  (PLEURITIS)  119 

A  patient  with  an  effusion  is  likely  of  his  own  volition  to  seek  the  bed; 
but  it  is  not  a  rare  happening  to  find  a  patient  up  and  about  and  en- 
deavoring to  attend  to  his  duties  with  one  pleural  sac  nearly  filled  with 
fluid. 

The  general  care  of  the  patient,  the  diet,  the  local  measures,  the  use 
of  drugs  and  the  relief  of  distressing  symptoms  are  the  same  in  the  sero- 
fibrinous  cases  as  in  the  fibrinous. 

Throughout  the  course  of  the  disease  the  patient  should  be  treated  as 
a  case  of  pulmonary  tuberculosis.  Fresh  air  night  and  day,  and  in  the 
open  as  much  of  the  day  as  possible,  and  an  abundance  of  good  food,  of 
which  milk  and  eggs  form  an  essential  part,  are  indicated. 

Dr.  Francis  Delafield  was  accustomed  to  take  issue  with  most  au- 
thorities of  his  time  on  at  least  three  points.  First,  he  gave  all  subacute 
cases  solid  food;  second,  he  kept  his  patients  with  effusion  out  of  bed  a 
good  deal,  even  if  the  afternoon  temperature  was  102°  F.  He  thought 
that  the  fluid  was  better  absorbed  and  that  the  patients  ran  down  less 
when  they  were  not  closely  confined  to  the  bed;  but  all  his  patients  had 
been  relieved  of  considerable  accumulations,  for  he  believed  in  early 
aspiration,  his  third  point. 

All  these  points  are  worthy  of  consideration. 

The  key-note  of  the  treatment  is  thoracentesis.  It  is  generally 
agreed  that  withdrawal  of  the  fluid  is  indicated  when  so  much  has  accu- 
mulated as  to  embarrass  the  respiration  or  circulation  as  shown  by  cyan- 
osis, dyspnoea  or  cardiac  weakness,  or  when  the  heart  is  frankly  displaced, 
even  in  the  absence  of  dyspnoea,  or  when  the  fluid  has  persisted  for 
two  or  three  weeks  in  spite  of  all  efforts  to  expedite  its  absorption.  But 
I  would  follow  the  teaching  of  Dr.  Francis  Delafield  that  thoracentesis 
should  be  done  early;  that  nothing  is  to  be  gamed  by  delay  but  much 
sacrificed  by  waiting. 

I  quote  his  own  words  which  succinctly  define  his  position  and  voice 
his  advice:  "  I  believe  that  aspiration  is  to  be  used  not  simply  to  remove 
fluid  from  the  chest,  but  to  cure  pleurisy  is  a  morbid  process"  and  fur- 
ther "this  means  that  as  aspiration  is  the  treatment  of  pleurisy,  it  is  to 
be  performed  as  soon  as  the  presence  of  fluid  in  the  chest  is  to  be  made 
out."  (Am.  Journal  of  Med.  Science,  1902,  Vol.  CXXIV.) 

Such  an  early  removal  of  fluid  not  only  shortens  the  disease,  but 
prevents  in  no  small  measure  the  formation  of  pleuritic  adhesions,  which 
are  commonly  very  extensive  after  expectant  treatment,  with  the  devel- 
opment of  bronchiectatic  cavities;  prevents  the  chronic  interstitial 
pneumonia  and  secondary  tuberculosis  of  the  lung  which  a  long  com- 
pression of  that  structure  facilitates. 
Dr.  Delafield's  teaching  was  to  aspirate  as  soon  as  the  chest  was  half 


120          TREATMENT  OF  ACUTE  INFECTIOUS  DISEASES 

full,  either  in  the  acute  or  subacute  case.  He  would  not  wait  for  em- 
barrassment of  respiration  or  circulation,  but  even  on  the  second  or 
third  day  of  the  attack,  if  the  chest  was  half  full,  evacuate. 

In  such  a  case  one  should  withdraw  all  that  ,the  aspirator  will  recover, 
but  if  the  chest  is  full  take  off  only  8  to  16  ounces  (250-500  c.c.)  at  the 
first  aspiration  to  avoid  serious  disturbance  of  the  heart  action..  The  rest 
of  the  fluid  may  be  absorbed;  if  it  reaccumulates,  further  tappings  are 
indicated. 

Exploratory  Puncture.  This  should  always  be  done  before  the 
aspiration  of  the  fluid  is  undertaken.  No  man  is  so  skilled  in  physical 
signs  that  he  can  score  100  per  cent,  in  his  diagnoses;  so  far  from  it, 
indeed,  that  to  the  best  of  diagnosticians  the  fruit  of  their  experience  is 
humbleness  of  spirit.  Confirm  the  diagnosis  of  an  effusion  by  an  explora- 
tory puncture  and  if  fluid  is  withdrawn  submit  it  to  microscopical  and 
bacteriological  examination. 

If  the  fluid  is  clear  an  aspiration  is  indicated;  if  purulent,  sooner  or 
later  an  operation. 

If  the  fluid  is  turbid,  some  judgment  must  be  exercised.  If  the  fluid 
cultures  out  streptococci  it  is  almost  certain  to  become  an  empyema  and 
is  to  be  treated  as  described  under  streptococcus  Empyema.  (See 
Chap.  X.) 

If  the  fluid  cultures  out  pneumococci,  which  grow  readily  and  the 
leucocytes  are  abundant,  and  some  necrotic,  it  should  be  treated  as  a 
pneumococcus  empyema.  (See  Chap.  IX.) 

If,  however,  the  leucocytes  are  few  and  the  pneumococci  do  not  grow 
well  on  culture,  a  thoracentesis  should  be  done.  It  might  be  mentioned 
that  sometimes  the  little  fluid  withdrawn  in  an  exploratory  puncture 
seems  to  initiate  absorption.  It  is  too  rare  a  happening,  however,  to 
warrant  delay  of  aspiration. 

For  the  Technique  of  Aspiration,  I  quote  from  my  own 
contribution  on  Pleurisy  to  Hare's  Modern  Treatment,  Vol.  I,  p. 
734. 

"For  aspiration  some  modification  of  the  Potain  apparatus  is 
commonly  utilized.  The  essentials  of  a  successful  aspirator  are  a  needle 
and  a  trocar  and  cannula,  to  which  a  rubber  tube  is  attached,  passing  to 
a  bottle  or  other  container,  which  in  turn  can  be  exhausted  by  a  pump 
or  other  device. 

It  is  well  to  have  a  piece  of  glass  tubing  introduced  into  the  rubber 
tube  to  enable  one  to  see  how  the  fluid  is  running. 

The  needle  is  the  easier  of  introduction,  but  has  the  disadvantage  of 
wounding  the  lung  if  it  comes  in  contact  with  it,  and  of  easily  getting 
plugged  with  fibrin.  The  trocar  and  cannula  are  more  difficult  to  intro- 


PLEURISY  (PLEURITIS)  121 

duce  and  of  more  intricate  mechanism,  but  free  from  the  above  objec- 
tions. 

The  needle  should  be  about  three  inches  long,  and  longer  for  a  thick 
chest,  and  one-sixteenth  to  one-twelfth  inch  in  diameter. 

The  tube  should  be  of  thick  firm  rubber,  and  about  a  yard  long.  There 
should  be  a  clamp  attached  with  which  to  regulate  the  flow — an  artery 
clamp  will  do. 

The  bottle  should  be  1500-2000  cubic  centimeters'  capacity  and  can 
be  readily  graduated  by  applying  strips  of  adhesive  plaster  at  the  levels 
of  given  quantities  previously  determined. 

The  bottle  may  be  exhausted  by  a  pump,  or,  better  yet,  by  a  clever 
device  of  Dr.  Karl  Connell,  namely,  by  burning  alcohol  which  has  been 
run  in  small  quantity  about  the  inside  of  the  bottle  and  stoppering  as  the 
flame  dies  out.  The  stopper  is  of  rubber  or  of  cork  and  is  perforated  by  a 
glass  tube,  to  which  the  rubber  tube  is  attached;  the  rubber  tube  is 
clamped,  of  course,  to  prevent  the  advent  of  air  into  the  bottle. 

All  this  apparatus  must  be  carefully  sterilized.  The  operator's  hands 
and  the  field  of  operation  should  receive  the  same  precautions  with  ref- 
erence to  cleanliness  as  in  surgical  procedures  of  greater  magnitude. 
Boiling  for  the  instruments  and  soap  and  water  and  alcohol  for  the  skin, 
are  the  best,  and  any  antiseptics  that  may  interfere  with  the  cultures 
desired  are,  of  course,  to  be  avoided. 

The  hypodermic  needle,  with  such  stimulants  as  may  be  needed, 
should  be  at  hand. 

The  best  position  for  the  patient  is  a  sitting  posture,  with  the  hands 
on  the  opposite  shoulders,  to  widen  the  intercostal  spaces.  The  site  of 
election  is  in  the  fifth  or  sixth  intercostal  spaces,  in  the  midaxillary  line 
or  in  the  seventh  space,  between  the  posterior  axillary  line  and  the 
scapular  line.  This  site  avoids  the  dome  of  the  diagram,  which  rises  as 
high  as  the  fourth  in  the  nipple  line,  the  sixth  in  the  midaxillary,  and  the 
eighth  in  the  scapular. 

Another  site  advised  is  an  inch  in  front  of  the  posterior  axillary  line, 
in  the  space  that  lies  just  below  the  angle  of  the  scapula.  It  is  easy  to 
reach,  the  space  is  wide  and  is  remote  from  important  organs. 

The  average  chest-wall  will  vary  from  four-fifths  inch  to  twice  that 
thickness.  Musser  has  given  the  distance  of  vessels  at  the  root  of  the 
lung  at  a  level  of  the  fourth  costochondral  junction  and  the  seventh 
dorsal  vertebrae  as  4  inches  on  the  right  side  in  the  midaxillary  line  and 
23/4  inches  on  the  left.  In  the  posterior  axillary  line  the  distance  on 
the  right  is  5  l/±  inches,  on  the  left  5  inches.  As  our  sites  are  below  this 
level  the  danger  of  puncture  is  less. 

A  local  anesthetic  is  rarely  necessary,  but,  if  the  patient  is  insistent 


122  TREATMENT  OF  ACUTE  INFECTIOUS  DISEASES 

or  nervous,  an  ethyl  chloride  spray  may  be  used  to  freeze  the  part,  or  a 
dilute  cocaine  solution  used  to  infiltrate  the  underlying  tissue. 

The  space  to  be  entered  should  be  clearly  palpated,  the  thumb  of  one 
hand  determining  the  edge  of  the  rib  below^  while  the  nail  serves  as  a 
guide  for  the  point  of  the  needle,  so  that  it  shall  be  kept  away  from  the 
intercostal  artery  that  hugs  the  rib.  The  needle  or  trocar,  witlj  the  blunt 
end  held  against  the  palm  of  the  hand,  and  the  forefinger  marking  off  the 
probable  thickness  of  the  chest  wall,  is  thrust  quickly  and  firmly  in  until 
non-resistance  to  its  advance  tells  of  the  entrance  into  the  cavity. 

In  some  cases  the  skin  may  be  so  thick  that  a  slight  incision  may  be 
needed  to  introduce  the  point  of  the  needle. 

The  coupling  should  now  be  made,  or,  if  already  made,  the  clamp 
should  be  loosened  gradually,  that  the  flow  may  be  slow. 

The  amount  of  fluid  to  be  withdrawn  depends  on  the  individual  case. 
It  depends  on  how  early  it  is  done,  how  much  fluid  is  in  the  chest,  and 
how  the  patient  reacts  .to  the  operation. 

Most  of  the  accidents  may  be  attributed  to  the  sudden  return  of  the 
blood  to  the  vessels  of  the  compressed  lung.  Hence,  if  the  fluid  is  with- 
drawn very  soon  after  its  appearance,  the  probability  of  much  compres- 
sion is  lessened,  and,  if  no  untoward  symptoms  set  in  during  the  proce- 
dures, all  may  be  allowed  to  drain  out  that  will.  If  the  amount  of  fluid 
is  large,  the  compression  will  be  greater,  and  still  more  if  it  has  been  left 
for  a  long  time. 

Much,  too,  depends  on  the  rapidity  of  the  aspiration,  for  if  the  fluid  is 
drained  off  slowly,  the  expanding  lung  and  its  filling  vessels  have  time  to 
readjust  themselves  to  the  new  condition  in  some  measure. 

If  there  is  much  fluid  and  everything  goes  on  well,  it  is  rarely  necessary 
to  take  more  than  1,500  cubic  centimeters,  and  the  better  part  of  half  an 
hour  should  be  consumed  in  doing  so.  The  balance  of  the  fluid  will  often 
disappear  promptly;  if  not,  another  tapping  can  be  done. 

If,  however,  either  coughing  or  severe  pain  or  dyspnoea  or  hemoptysis 
occurs,  or  heart  weakness  ensues,  the  procedure  should  be  stopped  at 
once  and  the  patient  put  in  a  recumbent  position. 

A  slight  feeling  of  faintness  may  arise  from  fear  of  operation.  This  is  to 
be  relieved  by  a  little  whisky  or  a  glass  of  cold  water. 

Pneumothorax  may  arise  from  puncture  of  the  lung,  entrance 
being  made  into  a  bronchus  or  cavity,  or  air  enter  by  the  needle  or 
trocar. 

While  fatal  cases  are  known  to  the  literature,  they  are  very  rare  and 
the  accident  need  not  cause  undue  alarm.  Sometimes  subcutaneous 
emphysema  may  be  caused  by  air  following  the  needle  from  the  punc- 
tured lung  on  its  withdrawal.  I  have  seen  these  results  on  more  than  one 


PLEURISY  (PLEURITIS)  123 

occasion.    Sometimes  the  absorption  of  air  was  rapid;  again  it  lingered 
for  some  days,  but  in  no  case  have  I  seen  alarming  symptoms. 

More  rare  and  more  formidable  is  the  appearance  of  pulmonary  edema 
with  abundant  albuminous  expectoration.  This  may  occur  during  the 
tapping  or  just  after,  and,  in  rare  instances,  later.  The  most  plausible 
explanation  is  transudation  from  the  congested  capillaries,  whose  walls 
have  undergone  impairment  of  their  integrity  during  compression. 

It  is  more  likely  after  withdrawal  of  large  amounts  of  fluid,  and  es- 
pecially when  rapidly  withdrawn.  There  may  be  cyanosis,  dyspncea, 
rapid  weak  heart  and  fall  of  blood  pressure. 

Another  accident,  fortunately  rare,  but  frequent  enough  to  make  its 
mention  of  importance,  is  the  sudden  onset  without  warning,  of  cyanosis 
and  dyspncea  with  weak  heart,  fall  of  pressure,  unconsciousness  and 
death.  Numerous  theories  have  been  advanced  to  account  for  it,  but 
none  have  been  so  suggestive  as  those  of  Joseph  Lewis  and  Dean  Capps, 
as  the  result  of  experiments  carried  on  in  the  Laboratory  of  Experimental 
Therapeutics  of  Chicago  University. 

They  attributed  these  accidents  to  the  result  of  irritation  of  the  in- 
flamed pleura  by  the  instrument  used. 

The  lessons  they  draw  are  that  great  care  should  be  taken  not  to  wound 
the  pleura  by  scratching  with  the  needle  and  for  that  reason  the  cannula 
is  preferable  to  the  needle. 

This  condition  is  to  be  met  like  that  of  shock  or  collapse  from  other 
causes,  the  most  valuable  drug  being  adrenalin."  (See  also  Pneumonia, 
Chap.  IX,  and  Empyema,  Chap.  X.) 

After  the  aspiration  we  anticipate  a  rapid  improvement  in  the  patient's 
symptoms,  drop  in  the  temperature  and  absorption  of  the  remaining 
fluid.  Unfortunately,  the  fluid  may  re-collect  in  some  cases  and  neces- 
sitate further  aspirations. 

After  the  fluid  was  removed,  or  in  small  accumulations,  it  was  Dr. 
Delafield's  routine  to  administer  diuretics,  acetate  of  potash,  caffeine, 
digitalis  and  others,  at  the  same  time  restricting  the  fluid.  I  must  confess 
that  this  measure  has  not  appealed  to  me  strongly,  but  I  can  see  no  objec- 
tions to  the  use  of  diuretics.  The  acetate  of  potash  or  the  citrate  of 
potash  could  be  used  in  gr.  xv-xxx  (1-2  Gm.)  doses  at  two  or  three 
hour  intervals  until  the  urine  becomes  alkaline. 

Caffeine,  citrated,  gr.  ii  ss.-iii  (0.150-0.2  Gm.)  or  the  double  salt  of 
caffeine  and  sodium  benzoate  or  salicylate  gr.  v  (0.33  Gm.)  may  be  given 
three  times  a  day,  or  diuretin  (the  double  salt  of  sodium  salicylate  and 
theobromin)  or  agurin  (the  double  salt  of  sodium  acetate  and  theo- 
bromin)  in  doses  of  gr.  viiss.-x  (0.5-0.66  Gm.)  three  times  a  day  or  theo- 
cine  (Theophylline)  gr.  v  (0.33  Gm.),  three  times  a  day,  but  these  should 


124  TREATMENT  OF  ACUTE  INFECTIOUS  DISEASES 

not  be  continued  over  more  than  two  or  three  days  at  a  time  and  theocin 
but  one  or  two  days. 

Digitalis  may  be  administered  as  the  infusion  gss.  (15  cc.)  three  times 
a  day  for  two  or  three  days  or  the  tincture  in  doses  of  m.  xxx  (2  c.c.)  for 
the  same  time  at  the  same  intervals. 

At  times  the  patient  seems  unable  to  control  the  process  until  a  change 
of  climate  or,  at  least,  of  environment  is  effected. 

Autoserotherapy,  the  injection  under  the  skin  of  the  patient 
of  1  or  2  c.c.  of  the  fluid  aspirated  fiom  his  chest,  repeated  every  second 
day  for  four,  five  or  six  times,  a  species  of  vaccination,  I  do  not  feel  able 
to  recommend.  I  have  had  no  experience  with  the  measure  and  have  not 
been  impressed  with  the  literature  on  the  subject. 

Convalescence.  This  is  not  established  as  long  as  there  is  pain, 
fever,  persistent  effusion  or  pulmonary  complications. 

If  the  patient  has  been  confined  to  bed,  he  should  not  be  allowed  up 
until  these  symptoms  have  disappeared,  unless  persistent  fluid  alone 
remains,  when  getting  up  does  seem  at  times  to  hasten  absorption.  (See 
Dr.  Delafield's  teaching  above.) 

Expanding  the  Lung.  Compression  of  the  lung  and  pleura!  adhe- 
sions remain  after  the  absorption  of  the  fluid  to  an  extent  dependent  on 
the  promptness  of  or  delay  in  aspiration. 

Inflation  of  the  lung  and  a  freer  play  between  pleural  surfaces  is 
effected  by  breathing  exercises.  They  must  be  undertaken  gradually 
and  if  pain  is  elicited  the  patient  should  desist  for  the  time. 

For  the  Technique  I  quote  from  Dr.  Fred  Lord's  excellent  ar- 
ticle on  pleurisy  in  Osier's  Modern  Medicine,  Vol.  Ill,  p.  832:  "Forced 
inspiration  from  six  to  twelve  times  every  two  hours  may  serve  as  a 
beginning.  Later,  with  each  inspiration,  the  outstretched  arm  on  the 
diseased  side  may  be  elevated  to  a  horizontal,  then  to  a  vertical  position, 
with  coincident  compression  of  the  sound  side  by  the  other  arm.  Lat- 
eral deviation  of  the  spine  toward  the  sound  side  during  inspiration 
more  forcibly  puts  the  diseased  side  on  the  stretch.  It  may  be  combined 
with  a  sirnilar  movement,  holding  both  arms  outstretched  at  right  angles 
with  the  body.  This,  as  well  as  torsion  of  the  trunk  with  the  arms 
similarly  placed,  should,  however,  be  preceded  by  simpler  exercises  and 
practiced  only  late  in  the  course." 

Another  method,  and  a  simple  one,  to  effect  the  same  purpose,  is 
to  have  the  patient  sit  on  an  armchair  with  the  sound  side  fixed  against 
the  arm  of  the  chair  by  grasping  the  rung  of  the  chair  on  that  side  with 
the  hand,  while  deep  inspirations  are  taken.  With  the  sound  side  thus 
splinted,  the  force  of  the  inspiration  is  expended  on  expanding  the  com- 
pressed lung  and  stretching  the  adhesions. 


PLEURISY  (PLEURITIS)  125 

A  time-honored  method  for  expanding  the  lung  is  blowing  through  a 
rubber  tube  attached  to  a  bottle  containing  water  and  transferring  the 
water  by  this  means  to  another  bottle  attached  to  the  first  by  a  rubber 
connection.  These  bottles  should  contain  about  a  gallon  each. 

After  Treatment.  The  primary  case  is  tuberculous.  For  this  rea- 
son treatment  of  the  patient  at  a  sanatarium  or  at  home,  just  as  a  case  of 
pulmonary  tuberculosis  is  treated,  until  the  patient  is  in  excellent  phys- 
ical condition  and  pulmonary  complications  have  been  eliminated  or 
stayed,  is  the  proper  procedure. 

If  this  cannot  be  done  fresh  air,  good  food,  as  much  rest  as  is  com- 
patible with  the  patient's  necessary  activities,  sleep  in  a  freely  ventilated 
room,  instructions  as  to  proper  hygienic  measures,  clothing,  and  atten- 
tion to  colds,  and  finally  careful  reexamination  of  the  lung  from  time  to 
time,  must  be  insisted  on. 

Acute  Purulent  Pleurisy.  Empyema.  The  key-note  of  the 
treatment  of  these  cases  is  evacuation  of  pus  by  operative  procedure. 
(See  Pneumococcus  Empyema  under  Pneumonia,  Chap.  IX  and 
Streptococcus  Empyema,  Chap.  X.) 

SUMMARY 

Dry  Pleurisy 

Confine  to  the  house. 

Milder  cases  need  not  remain  in  bed  unless  a  temperature  occurs. 
Severe  cases  confined  to  bed. 

Room,  bed,  care  of  the  body. 
(See  Pneumonia,  Chap.  IX.) 

Diet. 

(See  Chaps.  II,  IX  and  XIV.) 

If  no  fever  the  diet  should  be  liberal  and  such  as  is  given  a  tuberculous 
patient.  (See  text.) 

Drinks. 

Water,  fruit  juices  ad  libitum. 
Very  weak  tea. 
Milk  flavored  with  coffee. 

Bowels. 

Initial  cathartic  of  castor  oil  gss.  or  calomel  gr.  ii-iii  (0.120-02  Gm.) 

as  one  dose  or  gr.  Y±  (0.015  Gm.)  at  quarter-hour  intervals  for  six 

doses. 
Follow  calomel  in  4  to  6  hours  by  salts,  Epsom,  Glauber  or  Rochelle 

salt,  gss.  (15  Gm.). 

or  magnesium  citrate  gviii-xii  (240-300  Gm.). 


126  TREATMENT  OF  ACUTE  INFECTIOUS  DISEASES 

If  satisfactory  daily  stool  does  not  follow,  an  enema  may  be  given 

every  other  day  or  mild  salines  be  used. 
Colonic  irrigation  if  nature  of  stool  demands  it. 

Local  measures. 
Strapping  the  chest.     (See  text.) 
Ice  bag.    (See  text.) 
Heat.  (See  text.) 

Hot  water  bag. 

Electric  pad. 

Fomentations. 

Poultices. 

Counterirritants.  (See  text.) 
Mustard  plaster. 
Iodine. 

Actual  cautery. 
Blisters. 

Drugs. 

Salicylates.    (See  Acute  Rheumatic  Fever,  Chap.  III.) 

Acetyl  salicylic  acid  (aspirin)  gr.  x  (0.66  Gm.)  every  two  or  three 

hours. 
Sodium  salicylate  gr.  x-xv  (0.66-1.0  Gm.)  at  same  intervals. 

Coal  Tar  Preparations.     (See  text.) 
Do  not  use  if  circulation  is  impaired. 
If  pain  is  severe,  phenacetin  (acetphenetidin)  gr.  xv  (1  Gm.)  or  acetani- 

lid  gr.  v  (0.33  Gm.)  or  antipyrin  gr.  viiss.  (0.5  Gm.). 
Better  to  use  repeated  small  doses  as  phenacetin  gr.  iii  (0.2  Gm.)  or 

acetanilid  gr.  iss.    (0.10  Gm.)  combined  with  1  gr.  (0.06  Gm.)  of 

sodium  bicarbonate  and  citrated  caffeine,  gr.  ss.  (0.03  Gm.)  or 

antipyrin  gr.  ii  (0.120  Gm.)  (which  is  soluble). 
These  small  doses  may  be  repeated  every  M  to  J/£  hour  for  four  doses, 

depending  on  the  severity  of  the  pain,  then  at  hourly  intervals  for 

four  doses  and  then  every  two  hours. 
If  pain  is  not  relieved  by  the  above,  give  codeine  phosphate  gr.  1/8-1/2 

(0.008-0.03  Gm.)  hypodermically  or  intra-muscularly, 

or  morphine  sulphate  gr.  1/8-1/4(0.008-0.015  Gm.)  intramuscularly 

Cough  and  Dyspnoea. 

Due  to  pain  of  the  pleurisy. 
Relieved  by  above  measures. 

Pleurisy  with  Effusion 

General  care,  diet  and  local  measures  as  outlined  above. 
Treat  as  case  of  tuberculosis. 

Fresh  air,  sunlight,  abundance  of  good  food. 
Dr.  Delafield  differed  from  his  contemporaries  in  three  points:  e.  g. 

1.  Performing  early  aspiration. 


PLEURISY  (PLEURITIS)  127 

2.  Giving  solid  food  to  all  subacute  cases. 

3.  Keeping  patients  out  of  bed  a  good  deal  even  when  temperature 
was  102°  F. 

Thoracentesis. 

(See  text.) 

(See  Pneumonia,  Chap.  IX.) 

(See  Streptococcus  Pneumonia,  Chap.  X.) 

(See  Influenzal  Pneumonia,  Chap.  XII.) 

Exploratory  Puncture. 
Should  always  precede  aspiration. 
Culture  fluid. 

(See  text.) 
Dr.  Delafield  gave  diuretics  after  aspiration. 

(See  text.) 
Autoserotherapy. 

Not  recommended. 

Convalescence. 

Do  not  allow  up  until  fever,  pain,  the  effusion  or  pulmonary  com- 
plications have  disappeared. 
(See  text.) 
Expanding  the  lung. 

See  text. 
After  treatment. 

If  the  etiology  is  tuberculosis,  treat  patient  as  under  other  circum- 
stances. 
Sanitarium  treatment  best. 

Acute  Purulent  Pleurisy — Empyema 

Operation  for  evacuation  is  essential. 
(See  Pneumonia,  Chap.  IX.) 


CHAPTER  IX 

PNEUMONIA 

THE  term  Pneumonia  as  commonly  used  means  an  acute  infec- 
tion of  the  lung.  Such  an  infection  may  be  primary  or  may  be  secondary 
to  another  infection.  From  the  pathological  standpoint  two  great  groups 
of  pneumonias  are  recognized:  Lobar  Pneumonia  and  Broncho- 
pneumonia. 

Lobar  pneumonia  is  a  form  of  pneumonia  commonly  met  with  in 
adult  life  and  forms  a  considerable  percentage  of  the  pneumonias  of 
childhood. 

Broncho-pneumonia  is  particularly  common  in  infancy,  early  child- 
hood and  in  old  age.  It  is,  too,  the  common  form  of  secondary  pneu- 
monia. 

Lobar  pneumonia  is  characterized  pathologically,  by  an  intra-alveolar 
exudate  containing  a  great  deal  of  fibrin  and  no  interstitial  infiltration. 

Broncho-pneumonia  is  characterized  by  a  lesser  intra-alveolar  exudate 
with  far  less  fibrin  and  much  interstitial  infiltration  of  the  bronchial 
tissue  and  alveoli. 

Pleurisy  is  common  in  lobar  pneumonia;  in  broncho-pneumonia  the 
incidence  depends  on  the  nature  of  the  infecting  organism,  virulency  and 
the  nature  of  the  primary  disease  to  which  the  broncho-pneumonia  is 
secondary. 

Etiologically,  lobar  pneumonia  is  due  to  a  group  of  organisms,  having, 
morphologically  and  culturally,  features  in  common,  but  biologically 
divided  into  a  number  of  groups  each  inducing  a  specific  reaction  on  the 
part  of  the  tissues.  These  are  called  in  general  pneumococci  and  include 
the  streptococcus  mucosus  capsulatus  or  as  it  is  sometimes  called,  pneu- 
mococcus  mucosus  capsulatus.  A  small  group  of  cases  is  caused  by  the 
bacillus  of  Friedlander. 

Broncho-pneumonia  is  caused  by  a  variety  of  organisms,  including  the 
pneumococcus,  various  types  of  streptococci,  as  well  as  other  organisms, 
such  as  the  staphylococcus  the  micrococcus  catarrhalis,  the  influenza 
bacillus,  colon  bacillus  and  other  rarer  types. 

From  the  standpoint  of  prognosis,  immediate  and  remote,  it  is  desir- 
able to  determine  the  pathological  process,  but  the  most  urgent  problem 
that  faces  the  practitioner  is  to  establish  the  infecting  organism  as  upon 


PNEUMONIA  129 

the  success  of  this  depends  the  application  of  such  specific  treatment 
as  we  have  at  our  command. 

THERAPY 

Specific  Treatment 

Few  diseases  have  been  the  object  of  more  intensive  study  in  the  past 
five  years  than  pneumonia.  The  war  with  its  epidemics  of  primary 
and  secondary  pneumonia  and  the  recent  epidemic  of  influenzal 
pneumonia,  both  among  the  troops  and  in  civil  life,  have  added 
much  to  our  information  of  this  disease.  The  common  form  of  epi- 
demic pneumonia  as  met  in  civil  practice,  is  due,  with  rare  excep- 
tion, to  the  pneumococcus.  As  has  been  said,  these  pneumococci 
form  groups  closely  allied  to  each  other,  both  hi  their  appearance 
and  in  the  character  of  the  pathological  change  they  provoke,  but 
they  have  subtler  differences  of  great  significance  both  as  regards  the 
virulency  of  their  toxins  and  the  nature  of  these  toxins  and  of  substances 
elaborated  by  the  tissues  as  mechanisms  of  defense,  i.  e.,  the  immune 
bodies.  We  speak  of  these  differences  as  being  specific,  meaning  that 
each  group  is  a  distinct  entity;  one  might  say  we  are  dealing  with  so 
many  different  infections. 

Among  British  investigators,  as  many  as  eleven  different  types  have 
been  described.  But,  in  this  country  at  present,  for  practical  purposes, 
we  utilize  the  classification  of  Cole  and  his  co-workers.  They  have 
determined  four  types  of  organisms,  termed  Type  I.,  Type  II,  Type 
III,  Type  IV.  Types  I,  II  and  III  may  be  considered  as  homogeneous 
though  some  sub-groups  in  Type  II  have  been  described.  Type  III  is 
the  streptococcus  mucosus  capsulatus  or  pneumococcus  mucosus  cap- 
sulatus  previously  mentioned.  Type  IV  is  heterogeneous,  made  up  of  a 
large  and  undetermined  number  of  types.  Type  IV  includes  those  forms 
of  pneumococci  which  have  long  been  known  to  be  resident  in  normal 
mouths.  In  the  absence  of  epidemics  they  give  rise  to  the  pneumonias 
following  upon  undue  exposure  which  constitute  the  majority  of  the 
cases  as  seen  in  rural  practice. 

Types  I,  II  and  III  are  contagious  and  follow  only  when  an  individual 
has  been  exposed  to  those  who  are  suffering  from  a  pneumonia  due  to 
that  given  type  or  have  recovered  from  such  a  pneumonia,  but  still  carry 
in  the  secretions  of  their  upper  air  passages  virulent  organisms.  Such 
persons  are  technically  called  carriers.  Of  the  various  types  mentioned 
Type  I  is  the  most  common,  constituting  roughly  one-third  of  the  cases 
with  a  mortality  of  25-30  per  cent.  Type  III  is  the  most  virulent, 
affording  the  highest  mortality,  56  per  cent.,  but  fortunately  is  respon- 


130  TREATMENT  OF  ACUTE  INFECTIOUS  DISEASES 

sible  for  only  10  per  cent,  or  thereabouts,  of  the  cases.  The  type  giving 
the  lowest  mortality  (14  per  cent.)  is  Type  IV.  Up  to  the  present  time 
we  have  been  able  to  elaborate  a  serum  efficient  as  a  therapeutic  agent 
only  from  Type  I.  While  statistics  of  mortality  reduction  vary  greatly, 
one  would  scarcely  be  guilty  of  exaggeration  if  he  claimed  a  reduction 
from  25  per  cent,  to  one-half  or  one-third  that  number. 

The  efficiency  of  serum  treatment  depends  largely  upon  the  prompt- 
ness of  its  administration.  For  this  reason  the  first  step  taken  by  the 
practitioner  should  be  the  determination  of  the  nature  of  the  organism 
he  is  dealing  with  in  a  given  case  of  pneumonia  and  if  a  pneumococ- 
cus,  its  type.  His  ability  to  do  this  will  depend  largely  upon  the  lab- 
oratory facilities  at  his  command.  Where  these  are  excellent  he  should 
have  immediate  recourse  to  blood  and  sputum  cultures.  Taken  early, 
blood  cultures  are  positive  in  the  vast  majority  of  cases.  After  early 
days  of  infection  positive  blood  cultures  indicate  a  severe  infection. 
Moreover,  the  severity  of  the  infection  may  be  gauged  by  the  number  of 
colonies  on  the  plate.  As  soon  as  a  pure  culture  is  obtained,  the  organ- 
isms should  be  typed.  Sputum  sufficient  for  typing  and  cultures  may  be 
difficult  to  get  in  the  early  hours  of  the  illness.  This  makes  the  blood 
cultures  doubly  valuable,  but  as  soon  as  the  sputum  is  collected  it  should 
be  submitted  to  typing  and  culture.  Numerous  techniques  have  been 
devised  to  expedite  the  typing  of  the  organisms,  for  the  saving  of  a  few 
hours  may  mean  the  saving  of  a  life,  and  the  delay  necessitated  by  grow- 
ing out  the  organisms  may  sacrifice  the  patient.  Typing  depends  on 
three  varieties  of  reactions,  namely,  agglutination  and  precipitation, 
using  sputum  or  urine,  and  the  color  reaction  in  blood. 

The  agglutination  method  depends  on  the  clumping  of  the  organisms 
when  exposed  to  immune  serum  previously  prepared  against  this  organ- 
ism. 

The  precipitation  method  is  based  on  the  discovery  that  pneumococci 
produce  soluble  precipitin  antigens  when  growing  on  broth,  in  the  peri- 
toneal cavity  or  in  sputum.  These  antigens  are  also  in  the  urine  in  a  cer- 
tain per  cent,  of  cases.  This  precipitinogen  is  specific  and  will  cause  a 
cloudy  precipitate  to  form  in  the  anti-pneumococcus  serum  of  the  type 
to  which  belong  the  pneumococci  elaborating  it. 

Rosenow,  and  later  Longcope,  pointed  out  that  pneumococci  produce 
a  coagulum  when  grown  in  the  serum  of  patients  sick  with  pneumonia. 
The  chemical  reaction  involved  has  not  yet  been  explained  fully.  It  may 
be  due  to  acids  or  to  a  precipitinogen.  The  authors  of  the  blood  method 
of  typing  pneumococci  have  used  this  as  a  working  principle  and  found 
that  it  is  specific  for  different  types  of  pneumococci.  The  change  con- 
sists in  the  formation  of  hemoglobin  derivatives  which  give  a  dark 


PNEUMONIA  131 

brownish  red  gelatinous  clot.  The  reaction  may  be  evident  in  two  hours, 
but  the  average  time  is  from  6-8  hours.  The  technique1  of  this  test  is 
still  in  the  experimental  stage,  but  it  promises  to  be  of  great  value  as  it  is 
often  very  difficult  to  get  sufficient  sputum  early  in  the  disease  when  the 
serum  would  be  most  beneficial. 

The  simplest  test  for  typing  sputum  is  the  Krumwiede  test  and  the 
technique  may  be  adopted  by  the  general  practitioner.2  Where  it  is 

1  Loewe,  Hirschfeld,  &  Wallach;  /.  A.  M.  A.,  Vo.  13,  No.  3.     July  19,  1919, 
p.  170. 

2  Technique  of  Krumwiede- Valentine    method  of  typing    pneumococci  in 
sputum. 

1.  Sputum — free  from  saliva  as  possible,  by  coughing  repeatedly  and  spitting 
at  once  into  sterile  Petri  dish. 

2.  Send  to  laboratory  immediately.    If  delay  is  unavoidable,  keep  on  ice. 

Procedure : 

1.  Make  direct  smears  from  the  sputum  at  once.  Stain  one  by  Gram's 
method  and  a  second  with  Hiss'  capsule  stain.  This  gives  an  idea  of  the  bacter- 
iology and  is  a  guide  in  procedure.  Group  III  may  sometimes  be  recognized  by 
the  large  distinct  capsule  seen  on  both  smears. 

"Technic: 

"From  3  to  10  c.c.  of  the  sputum  depending  on  the  amount  available,  is 
poured  from  the  sputum  container  into  a  test  tube.  This  is  placed  in  boiling 
water  for  several  minutes  or  longer  until  a  more  or  less  firm  coagulum  results, 
which  will  occur,  if  the  specimen  is  a  suitable  one.  The  coagulum  is  then 
broken  up  with  a  heavy  platinum  wire  or  glass  rod,  and  saline  is  added.  Just 
enough  saline  should  be  added  so  that,  on  subsequent  centrifuging,  there  will 
be  sufficient  fluid  to  carry  out  the  test.  If  too  much  is  added,  the  resulting 
antigen  may  be  too  dilute.  In  some  instances  little  or  no  saline  is  necessary, 
as  sufficient  fluid  separates  from  the  coagulum. 

"After  the  addition  of  the  saline,  the  tube  is  again  placed  in  boiling  water  for  a 
few  minutes  to  extract  the  soluble  antigen  from  the  coagulum,  the  tube  being 
shaken  several  times  during  the  heating.  The  broken  clot  is  then  thrown  down 
by  centrifuge,  and  the  clear  supernatant  fluid  used  for  the  test.  To  hasten 
the  appearance  of  the  reaction  and  to  obtain  a  reaction  even  should  the  antigen 
be  dilute,  we  layer  the  antigen  over  the  'type'  serums,  using  the  latter  un- 
diluted. Two-tenths  c.c.  of  the  three  'type'  serums,  are  placed  in  narrow  test 
tubes,  and  the  antigen  added  from  a  capillary  tube  with  a  rubber  teat.  If  the 
tubes  containing  the  serum  are  tilted  and  the  antigen  dropped  slowly  on  the 
side  of  the  tube  just  above  the  serum,  no  difficulty  will  be  encountered  in  obtain- 
ing sharp  layers,  as  the  undiluted  serum  is  sufficiently  higher  in  its  specific 
gravity.  The  tubes  are  then  placed  in  the  water  bath  at  from  50°  to  55°C., 
and  observed  after  several  minutes. 

"If  a  fixed  type  was  present  in  the  sputum,  and  should  the  sputum  have  been 
rich  in  antigen,  a  definite  contact  ring  is  seen  in  the  tube  containing  the  homol- 
ogous serum.  With  sputums  less  rich  in  antigen,  the  ring  may  develop  more 
slowly,  and  it  will  be  less  marked.  Some  experience  is  necessary  in  detecting 


132  TREATMENT  OF  ACUTE  INFECTIOUS  DISEASES 

possible  it  is  wise  to  confirm  this  test  by  the  mouse  method  which  is  a 
more  dependable  one  although  it  requires  more  time  before  a  report  can 
be  made  and  necessitates  using  white  mice.1  If  this  is  not  feasible  one 
may  use  the  artificial  mouse  method.  For  the  details  of  the  technique 
one  should  consult  text-books  on  laboratory 'methods. 

Urine  may  also  be  used  where  sputum  is  not  available  and  in  view 
of  the  fact  that  the  technique2  is  simple  and  rapid  it  would  seem  an  ad- 
vantage to  test  the  urine  for  precipitins  as  soon  as  a  case  is  suspected  of 
being  pneumonia,  for  Quigley  says  that  they  may  be  present  as  early  as 
the  second  day  of  the  disease. 

If  the  organism  is  found  to  be  Type  I,  immune  serum3  should  be 

the  less  marked  contact  rings  and  in  differentiating  them  from  an  apparent 
ring  which  may  be  confusing,  if  one  of  the  sera  is  darker  in  color,  giving  thus  a 
sharper  contrast  with  the  supernatant  antigen.  The  true  ring  is  more  or  less 
opaque,  and  this  quality  can  be  seen  by  tilting  the  tubes  and  looking  at  the  area 
of  contact  against  a  dark  background,  for  example;  the  lower  edge  of  a  dark 
shade  raised  to  just  above  the  level  of  the  eyes.  The  advantage  of  the  ring  test 
is  that  a  ring  may  be  evident,  whereas  definite  clouding  or  a  visible  precipitate 
may  appear  only  after  longer  incubation  or  may  be  so  slight  even  after  an  hour's 
incubation  as  to  leave  one  in  doubt.  It  is  well  to  shake  the  tubes  after  twenty 
minutes  as  many  of  the  specimens  will  show  definite  clouding  or  precipitate 
either  at  once  or  on  further  incubation,  thus  checking  the  ring  reading."  Krum- 
wiede  and  Valentine,  J.A.M.  A.,  Vol.  70,  No.  8,  p.  573,  February  23,  1918. 

1  Blake:  Jour.  Exper.  Med.,  Vol.  26,  No.  1,  July,  1917. 

2  Small  quantities  of  urine  are  clarified  by  centrif  ugation  and  stratified  with 
equal  amounts  of  immune  serum  of  the  different  types  in  small  agglutination 
tubes,  incubated  in  the  water  bath  at  37°  C  for  one  hour  and  observed  at  inter- 
vals.     The  precipitate  usually  appears  in  15  minutes,  but  may  need  to  wait 
one-half  to  one  hour.    (It  is  essential  that  all  the  reagents  used  should  be  clean.) 
Quigley  got  81  per  cent,  of  positive  results  in  the  urines  of  82  cases  of  Types 
I,  II,  III.  The  strength  of  the  reaction  gradually  increased  during  three  or  four 
days  and  persisted  two  to  ten  days  .and  gradually  disappeared.    The  day  of 
its  appearance  is  not  regular,  the  earliest  was  on  the  second  day  of  the  illness. 
Quigley:  /.  Infect.  Dis.,  Sept,  18. 

3  The  Production  of  Antipneumococcus  Serum.      The  choice  of  animal  to  be 
used  in  the  production  of  an  antipneumococcus  serum  has  been  determined  by 
the  facts;  that  we  must  have  a  healthy  animal,  free  from  a  tendency  toward 
joint  infections,  and  a  large  animal,  capable  of  furnishing  a  comparatively  large 
volume  of  blood  at  rather  frequent  intervals.    To  meet  these  requirements  a 
draft  horse  has  been  found  most  suitable. 

The  nature  of  the  antigen  to  be  used  has  been  the  subject  of  much  experimen- 
tation. At  present,  injections  of  both  killed  and  living  pneumococci  are  con- 
sidered necessaiy  to  produce  a  serum  containing  the  required  strength  of  ag- 
glutinating bodies  and  the  proper  protecting  power;  that  is,  a  serum,  that,  when 
diluted  1:200,  will  cause  an  agglutination  of  pneumococci  Type  I.  and  0.2  c.c. 
of  which  will  protect  a  mouse  against  0.1  c.c.  of  a  virulent  culture  of  pneu- 
mococci. 


PNEUMONIA  133 

administered  at  once.  The  importance  of  these  procedures  pleads  for 
community  laboratories  in  more  sparsely  settled  districts.  If  it  is  not 
possible  for  the  practitioner  to  determine  the  type  of  the  organism  in  a 
case  in  which  the  clinical  evidence  is  positive  for  lobar  pneumonia,  he  has 
to  consider  the  advisability  of  administering  Type  I  on  the  percentual 
chance  of  the  case  concerned  being  due  to  Type  I.  Under  no  circum- 
stance is  the  practitioner  justified  in  neglecting  the  typing  where  it  is 
possible,  but  if  Type  I  furnishes  25-33  per  cent,  of  the  cases  of  epidemic 
lobar  pneumonia  it  does  not  seem  to  me  that  the  patient  should  be  de- 
prived of  the  chance  that  such  a  choice  affords.  It  must  be  remembered, 
however,  as  has  been  mentioned,  that  in  country  districts  where  it  can 
be  proven  that  the  patient  has  not  been  subjected  very  recently  to  infec- 
tion in  town  or  city,  that  Type  I  cases  are  relatively  rare  and  Type  IV 
the  rule.  In  any  case  all  precautions  should  be  taken  in  the  administra- 
tion of  the  serum  to  avoid  the  accidents  that  can  occur  to  those  that  are 
anaphylactic.  Patients  should  be  instructed  to  tell  their  physicians  that 
they  have  had  serum  should  the  occasion  ever  arise  for  a  second  adminis- 
tration of  serum  of  any  kind  derived  from  a  horse.  This  is  done  in 
anticipation  of  anaphylactic  manifestations. 
Administration  of  Serum.  If  it  has  been  determined  in  any 

The  bacteria  used  for  the  preparation  of  the  antigen  must  be  virulent  for  man: 
they  must  not  have  been  long  under  cultivation;  must  have  gone  through  but 
few  passages  in  animals;  the  broth  culture  must  be  only  12-15  hours  old;  the 
virulency  is  tested  on  mice  or  rabbits. 

The  method  of  procedure  is  then:  to  select  a  sound  draft  horse  and  test  him 
for  glanders  by  complement  fixation. 

Under  sterile  precautions  to  draw  20  c.c.  of  blood  from  the  jugular  vein  and 
to  keep  this  for  a  control.  To  inject  intravenously  daily  for  six  days  20-30  c.c. 
of  an  emulsion  of  killed  pneumoccocci  from  50  c.c.  of  a  12-15  hour  old  culture  of 
virulent  pneumococci;  to  let  the  animal  rest  for  seven  days  and  then  repeat 
the  injections.  On  the  sixth  day  of  the  second  series,  to  draw  a  specimen  of 
blood  and  test  for  agglutination  and  protective  power.  If  it  measures  up  to  the 
standard,  bleed  the  horse.  This  has  rarely  occurred  and  it  is  usually  necessary 
to  give  1-3  or  more  series  of  live  organisms  in  this  manner:  8-10  days  after  the 
second  series  of  injections,  give  a  series  of  three  intravenous  injections  of  a  live 
broth  culture,  beginning  with  20  c.c.  and  doubling  the  dose  each  day  (that  is,. 
40,  80  c.c.)  unless  the  temperature  rises  above  104.9°  F.  If  the  temperature  is 
above  this  level,  decrease  the  dosage  accordingly. 

Wait  six  days  the  after  first  injection,  take  a  specimen  of  blood  as  before;  if  it 
is  up  to  standard,  bleed  the  horse,  if  not,  repeat  the  injection  of  live  bacteria, 
using  respectively  100,  150,  200  c.c.  of  the  broth,  being  guided  by  temperature 
as  before;  wait  six  days  and  test  the  blood  as  before;  if  it  is  weak  give  a  third 
series  of  live  cultures  and  of  the  same  volume  as  the  second  series  and  test  the 
blood  as  before.  After  bleeding  the  horse,  allow  it  to  be  quiet  for  3-4  days  and 
then  give  series  of  three  injections  of  living  bacteria  and  after  seven  days  test 
the  serum.  If  it  is  of  the  desired  strength,  bleed  the  horse  again. 


134          TREATMENT  OF  ACUTE  INFECTIOUS  DISEASES 

given  case  to  administer  serum,  the  first  step  to  be  taken  is  to  discover 
whether  the  patient  is  or  is  not  sensitized  to  horse  serum.  This  is  a  step 
too  often  neglected,  but  the  neglect  always  entails  a  risk  that  not  infre- 
quently results  in  discomforts  and  alarm  on  the  part  of  the  patient,  and 
may  in  rare  instances  be  followed  by  sudden  death.  For  this  reason  it  is 
important  to  take  a  careful  history  of  the  patient.  One  should  never  fail 
to  make  inquiry  as  to  the  previous  administration  of  serum  and  the 
history  of  asthmatic  attacks  should  be  particularly  elicited.  The  pre- 
vious administration  of  serum  entails  severe  urticaria  in  many  cases; 
anaphylactic  shock  must  be  the  rarest  of  occurrences.  In  asthmatics 
sensitized  to  horse  emanations,  however,  much  more  violent  reactions, 
severe  asthma  and  death  may  ensue,  unless  the  patients  are  properly 
desensitized.  As  the  technique  of  the  desensitization  is  not  difficult  and 
entails  only  a  little  more  time  at  the  bedside  every  conscientious  practi- 
tioner will  have  recourse  to  this  precaution  before  going  further. 

This  sensitization  or  as  it  is  sometimes  technically  termed  anaphy- 
lactic state  constitutes  one  of  the  most  interesting  chapters  in  modern 
medical  research.  It  may  well  be  of  the  nature  of,  or  a  step  towards, 
immunity  as  we  witness  it  in  infectious  diseases.  The  rationale  of  the 
condition  would  then  depend  upon  the  body's  effort  to  dispose  of  foreign 
substances  whenever  introduced  into  the  blood  stream  and  tissues  by 
any  avenue  of  entrance.  Protein  substances,  whether  derived  from 
bacterial  bodies  as  in  disease  or  from  other  sources,  are  destroyed  within 
the  living  tissues  by  substances  akin  to  ferments,  which  are  elaborated 
by  the  body  cells  on  the  occasion  of  the  demand.  These  substances  are 
termed  immune  bodies,  while  the  protein  that  has  given  rise  to  their 
production  is  called  the  antigen.  The  action  of  the  immune  body  upon 
the  antigen  results  directly  or  indirectly  in  the  formation  of  toxic  bodies, 
giving  rise  to  certain  manifestations.  These  considerations  are  at  present 
largely  theoretical.  The  immune  substances  are  assumed  to  attach 
themselves  to  the  body  cells  until  they  are  produced  in  such  numbers  as 
to  more  than  satisfy  the  affinities  of  the  body  cells  when  the  excess 
circulates  free  in  the  blood  stream.  At  this  stage  immunity  is  estab- 
lished and  the  immune  substances,  combining  with  the  foreign  protein, 
dispose  of  it  without  injury  to  the  body  cells,  but  if  the  excess  of  immune 
bodies  circulating  free  in  the  blood  has  not  yet  been  attained,  then  the 
foreign  protein  is  acted  upon  by  the  immune  bodies  attached  to  the  body 
cells  which  are  thus  brought  into  intimate  contact  with  the  toxic  sub- 
stances elaborated,  to  their  detriment.  This  halfway  stage  is  called 
anaphylaxis  and  begins  in  10-14  days  after  the  administration  of  serum 
and  continues  indefinitely.  (In  case  one  is  in  doubt  about  the  time  for  a 
second  intravenous  injection  of  serum  one  should  inject  subcutaneously 


PNEUMONIA  135 

every  third  day,  y^  to  1  c.c.  of  horse  serum  to  perpetuate  the  immunity 
established.)  The  manifestations  of  anaphylaxis  vary  in  degree  and 
kind.  They  may  be  violent,  constituting  the  condition  known  as  ana- 
phylactic  shock,  characterized  by,  in  some  instances,  sudden  collapse  and 
death,  occurring  with  lightning-like  rapidity;  or  it  may  be  less  violent 
and  cause  suffusion  of  the  face,  marked  restlessness,  increased  heart 
rate  and  not  infrequently  a  most  distressing  dyspnoea,  due  to  the  sharp 
contraction  of  the  bronchial  muscles  which  results  in  extreme  distension 
of  the  alveoli  from  which  the  air  in  expiration  cannot  escape  as  a  result 
of  the  valve-like  actions  of  the  folds  of  soft  mucous  membrane.  In  such  a 
case  I  have  witnessed  the  escape  of  air  into  the  mediastinum  and  fascial 
tissues  of  the  neck.  These  symptoms  may  or  may  not  be  followed  by  a 
fatal  issue  from  a  circulatory  collapse.  Massive  urticaria  is  a  common 
manifestation. 

Determination  of  Sensitization.  The  technique  followed  in  de- 
termining sensitization  is  here  outlined:  use  a  syringe,  graduated  in 
hundredths, — the  sub  Q  tuberculin  syringe  is  a  good  example, — with  a 
very  fine  needle,  a  No.  28  is  to  be  preferred.  Cleanse  the  skin  over  the 
forearm  with  alcohol,  not  wiping  vigorously,  and  carefully  avoiding 
making  the  skin  red.  Inject  intradermally  0.02  c.c.  of  a  solution  of 
horse  serum  (or  if  this  cannot  be  obtained  the  antipneumococcus  serum 
may  be  utilized  for  this  purpose)  which  has  been  diluted  1 :10  with  sterile 
normal  saline  solution  (0.9  per  cent.),  i.  e.,  0.002  c.c.  of  undiluted  horse 
serum.  It  must  be  remembered  not  to  inject  under  the  skin,  but  be- 
tween its  layers.  As  a  control,  some  two  inches  distant  from  the  site 
and  at  the  same  level,  inject  an  equal  volume  of  sterile  saline  in  the 
same  manner.  If  the  injection  is  correctly  done  there  will  appear  a 
small,  blanched  wheal,  showing  depressions  of  the  hair  follicles.  This 
wheal  disappears  in  a  few  minutes  as  the  fluid  diffuses  into  the  tissues. 

If  the  patient  is  sensitive  there  will  develop  in  a  half  an  hour  to  an 
hour  an  urticarial  wheal  at  the  site  of  the  injection;  this  will  be  sur- 
rounded by  an  area  of  erythema  and  the  degree  of  sensitiveness  is  roughly 
proportional  to  the  size  of  the  reaction.  If  there  is  no  reaction  we  pro- 
ceed to  the  administration  of  the  serum. 

Desensitization.  If  a  positive  reaction  has  been  obtained  we 
endeavor  to  desensitize  the  patient.  If  the  reaction  is  very  slight  or 
doubtful,  the  very  slow  introduction  of  serum  noted  below  is  sufficient 
or,  and  this  procedure  is  advisable  in  any  case,  one  should  give  H  to 
1  c.c.  of  the  horse  serum  (or  antipneumococcic  serum)  subcutaneously  at 
least  an  hour  before  the  intravenous  introduction  of  the  antipneumo- 
coccus serum.  If  the  patient  has  a  striking  reaction  or  if  there  is  a  dis- 
tinct history  of  asthma  and  more  especially  horse  asthma,  even  greater 


136  TREATMENT  OF  ACUTE  INFECTIOUS  DISEASES 

precautions  should  be  taken  by  desensitizing  the  patient  with  repeated 
small  injections.  Besredka  prefers  to  attain  this  end  by  introducing  the 
serum  intravenously,  because  immunity  can  be  established  by  it  in  10  to 
15  minutes  and  followed  at  once  by  a  large  dose  of  serum  without  remov- 
ing the  needle  from  the  vein.  His  directions iare: — 

"We  begin  by  testing  this  sensitiveness  by  introducing  intravenously 
as  small  a  dose  as  is  desired — 0.1  c.c.  of  serum,  for  example.  (The  serum 
is  diluted  to  ten  times  its  volume  with  physiological  saline  solution,  and 
1  c.c.  of  this  solution  is  injected.)  If  the  patient  does  not  react  at  the 
end  of  three  to  five  minutes,  another  injection  of  0.3  c.c.  of  serum  is  given 
(3  c.c.  of  the  dilution)  without  withdrawing  the  cannula.  We  wait  again 
two  minutes,  and  if  nothing  happens  we  inject  1  c.c.  of  serum  (10  c.c.  of 
dilution).  At  this  moment  anti-anaphylactic  immunity  is  acquired,  but 
for  further  security  after  a  further  interval  of  two  minutes,  we  make  a 
last  injection  of  2.5  c.c.  of  serum  (25  c.c.  of  dilution).  Whatever  may 
have  been  the  degree  of  the  patient's  hypersensitiveness  before  this 
vaccination,  we  can  be  certain  that  he  will  now  tolerate,  without  the 
least  trouble  20-40  c.c.  of  undiluted  serum  at  any  stage  of  the  illness." 
Besredka  states  that  vaccination  to  obtain  immunity  may  be  given 
subcutaneously  by  injecting  1  to  5  c.c.  of  serum,  but  that  one  should 
wait  four  hours  before  injecting  the  full  dosage.  Some  individuals  are  so 
extremely  sensitive  to  subcutaneous  injections  that  the  only  safe  method 
is  the  intravenous  one. 

The  method  of  desensitization  used  by  Cole  and  his  co-workers  and 
described  in  Monograph  No.  7  of  the  Rockefeller  Institute  for  Medical 
Research,  is  as  follows: 

"This  should  consist  in  giving  extremely  small  amounts  of  serum 
subcutaneously  at  J^  hour  intervals,  doubling  the  size  of  the  dose  at  each 
injection.  One  can  safely  begin  with  the  injection  of  0.025  c.c.  of  serum. 
If  no  reaction  follows  the  injection  of  1  c.c.,  subsequent  doses  may  be 
given  intravenously,  also  at  J/£  hour  intervals,  beginning  with  0.1  c.c. 
and  doubling  the  dose  at  each  injection.  If  a  general  reaction  recurs,  or 
cyanosis,  dyspnoea  or  increased  rapidity  of  the  heart  rate  supervenes, 
the  injections  should  be  suspended  for  2  to  4  hours,  depending  upon  the 
severity  of  the  reaction,  and  then  be  resumed,  starting  with  the  same  dose 
as  that  producing  the  reaction.  After  25  c.c.  of  serum  have  been  given 
in  these  small  doses,  after  a  lapse  of  4  hours,  50  c.c.  may  be  given,  fol- 
lowed by  the  regular  dose  6  to  8  hours  later." 

Serum  Administration.  Precautions.  This  is  a  surgical  pro- 
cedure and  surgical  precaution  should  be  used.  Sterile  gloves,  towels 
and  gauze  are  very  desirable  though  not  absolutely  essential.  They  all 
may  be  obtained  by  methods  detailed  below. 


PNEUMONIA  137 

Serum  very  frequently  contains  a  sediment  and  one  should  avoid 
stirring  this  up;  if  sterile  pipettes  are  at  hand  it  is  well  to  pipette  the 
serum  from  the  bottle  rather  than  pouring  it  out. 

As  the  serum  is  quite  viscous,  it  flows  better  through  the  needle  if  it  is 
diluted.  As  a  diluent  we  use  normal  saline.  It  is  absolutely  essential 
that  this  solution  be  prepared  fresh  from  freshly  distilled  and  if  possible 
doubly  distilled  sterile  water  in  order  to  prevent  undesirable  reactions 
as  explained  hereafter.  If  proper  saline  is  not  obtainable,  give  the  serum 
undiluted. 

Further,  to  avoid  unnecessary  reactions  the  serum  should  be  given  at 
or  a  little  above  body  temperature,  and  very  slowly. 

After  sterilization  in  undistilled  water  all  apparatus  should  be  thor- 
oughly rinsed  in  the  special  saline  to  remove  the  plain  water  which  tends 
to  cause  unfavorable  reactions. 

Inspect  the  patient's  arm  before  starting  the  work  to  ascertain  how 
accessible  the  vein  is  and  hence  the  apparatus  which  will  be  needed. 

Apparatus  Needed: 

1.  Two  number  16  or  18  needles,  preferably  Luer,  and  two  adapters 
to  fit. 

2.  Three  feet  of  new  rubber  tubing  5  mm.  inside   diameter  inter- 
rupted by  three  inches  of  glass  tubing  which  allows  one  to  inspect  the 
flow. 

3.  One  graduate  of  100  c.c.  capacity. 

4.  A  container:  a  Kelley  flask  is  best.    The  barrel  of  a  60  to  120  c.c. 
syringe  or  a  three-inch  funnel  will  answer. 

5.  Two  clamps:  a  Moore  and  a  screw  type  are  best.    Two  artery 
clamps  will  suffice. 

6.  A  tourniquet  of  rubber  or  gauze. 

7.  A  20  c.c.  Luer  syringe. 

8.  A  hypodermic  syringe  and  needle. 

9.  Pitcher,  beaker  or  other  vessels  of  250  c.c.  capacity. 

10.  Rubber  gloves. 

11.  Towels. 

12.  Gauze. 

13.  Adrenalin  (epinephrin)  solution  1:1000. 

14.  Mercuric  bichloride  solution  1 :1000. 

15.  50  per  cent,  alcohol. 

16.  95  per  cent,  alcohol. 

17.  Tincture  of  iodine. 

18.  Adhesive  plaster. 

19.  Rubber  sheet  or  newspapers. 


138  TREATMENT  OF  ACUTE  INFECTIOUS  DISEASES 


Serum  Apparatus 


Kelly  flask 


Rubber  tube 
Moore   clamp 

Glass   insert 
Rubber  tube 


Adapter 
Screw  *I8  Needle 

Clamp 


PNEUMONIA 


139 


Serum    Apparatus 


Graduations 
in  glass  pencil 


Glass  tube 
for  air  vent 


Rubber  tube 


uspension  hook 


^Adhesive  straps 


Rubber  stopper 

Glass  tubing 

Rubber  tubing 
Moore  clamp 

Glass  insert 


,  Adapter*)8 Needle 
bcrew 
clamp 


140;          TREATMENT  OF  ACUTE  INFECTIOUS  DISEASES 

If  vein  is  inaccessible: 

1.  Two  artery  clamps. 

2.  Two  pairs  of  four-inch  forceps. 

3.  One  pair  of  straight  scissors. 

4.  One  cahnula — Webster  style  preferred. 

5.  Sterile  catgut,  No.  I. 

6.  Sterile  bandage. 

7.  Straight  needle. 

Assembling  of  Apparatus. 

(This  should  not  be  done  in  the  patient's  room.) 

(See  diagrams  I  and  II.) 

Connect  the  container1  with  the  rubber  tubing  which  is  interrupted 
by  the  glass  tubing  inserted  about  four  or  five  inches  from  the  end  distal 
to  the  container. 

Apply  loosely  the  Moore  clamp  to  the  long  rubber  tubing  and  the 
screw  clamp  to  the  shorter  piece  as  shown  in  the  diagram.  ' 

Connect  the  adapter  to  the  short  length  of  the  rubber  tube. 

Sterilizing  Apparatus.  Place  the  apparatus  thus  set  up,  the  gradu- 
ate and  pitcher,  etc.,  in  a  vessel  that  can  be  closed  and  pour  over  them 
warm  water  sufficient  to  just  cover  them.  Close  tightly  and  boil  for  20 

1 A  much  more  convenient  device,  if  opportunity  affords,  utilizes  as  a  container 
a  flat-bottom  bottle  of  500  c.c.  capacity.  The  advantages  of  this  are  that  it  can 
be  set  flat,  that  it  can  be  used  as  a  mixing  vessel  and  so  does  away  with  an  extra 
vessel  and  an  unnecessary  transference  of  the  serum. 

The  setting  up  of  the  apparatus  is  simple:  through  a  two-hole  rubber  stopper 
insert  two  glass  tubes,  one  of  which  extends  to  the  bottom  of  the  bottle  and  acts 
as  an  air  vent  and  the  other  goes  only  just  through  the  stopper  and  carries  the 
serum. 

The  procedure  is  the  same  as  given  above,  i.  e.,  the  rubber  tubing  is  connected 
with  the  short  glass  tube;  the  system  is  rinsed  with  saline  and  the  serum  and 
saline  are  measured  into  the  bottle  and  mixed.  The  bottle  and  tubing  are  put 
in  water  at  110°  F.,  taking  care  to  preserve  the  sterility  of  the  adapter. 

When  ready  to  give  the  serum  the  bottle  is  inverted  and  suspended  at  about 
24  inches  above  the  patient's  arm.  The  needle  is  put  on  the  adapter  and  the 
rubber  tube  raised  and  lowered  until  all  the  air  bubbles  are  removed  from  the 
tubing  as  shown  by  the  cessation  of  bubbling  of  the  serum  when  the  tubing  is 
raised.  Then  adjust  the  screw  clamp  so  that  15  drops  of  the  serum  flow  per 
minute  from  the  needle.  Leave  the  screw  clamp  thus  adjusted  and  apply  the 
Moore  clamp.  Proceed  as  given  above. 

It  is  a  matter  of  convenience  in  judging  the  rate  of  flow,  if  graduations  are 
made  on  the  bottle  with  a  glass  pencil.  (See  Diagram  II.) 

The  Lederle  Antitoxin  Laboratories  now  furnish  a  most  convenient  intraven- 
ous outfit  for  administering  antipneumococcus  serum.  It  is  accompanied  by 
specific  directions  and  one  may  have  recourse  to  it  in  any  emergency  where  the 
above  apparatus  is  not  available. 


PNEUMONIA  141 

minutes.  If  one  has  no  sterile  goods,  immerse  towel,  gauze,  etc.,  in  1 :1000 
solution  of  mercuric  bichloride  for  at  least  10  minutes.  In  the  meantime 
prepare  the  serum  and  patient.  A  few  minutes  before  needles  are  needed, 
drop  them  in  boiling  water,  cover  and  allow  them  to  boil  for  five  minutes, 
pour  off  the  water  and  let  them  stand  in  the  covered  sterilizer. 

I.  Preparation  of  the  Serum.  Immerse  the  sealed  bottle  of  serum 
for  10  minutes  in  bichloride  of  mercury  solution  1 :1000,  at  a  temperature 
of  110°  F.  (Higher  temperature  will  coagulate  the  serum.) 

Remove  the  bottle  from  the  bichloride,  dry  on  sterile  gauze  and  pour 
sterile  normal  salt  solution  over  the  stopper  to  remove  the  bichloride  and 
again  dry  the  stopper  with  sterile  gauze.  Remove  the  stopper,  pour  the 
first  few  cubic  centimeters  of  the  serum  into  a  waste  pan  to  avoid  con- 
tamination from  the  mouth  of  the  bottle.  (Do  not  shake  the  bottle  and 
disturb  the  sediment  in  the  serum.) 

Measure  90  to  100  c.c.  of  the  serum  in  the  sterile  graduate,  pour  into 
the  sterile  pitcher  and  add  an  equal  volume  of  freshly  distilled  and  freshly 
sterilized  normal  (0.9  per  cent.)  saline  solution  at  a  temperature  of 
110°  F.  and  mix  thoroughly.  (If  proper  saline  is  not  obtainable,  give 
serum  undiluted.)  Cover  pitcher  with  sterile  cloth  and  stand  it  in  a 
pan  of  water  at  110°  F.  until  it  is  to  be  used. 

When  the  apparatus  is  sterile  drain  off  all  the  plain  water  that  it 
contains  and  rinse  it  with  freshly  distilled  sterile  normal  saline  solution. 
Then  replace  all  the  air  in  the  tubes  by  saline,  connect  the  adapter  with 
the  needle  and  adjust  the  screw  clamp  so  that  15  drops  of  saline  run  from 
the  needle  in  one  minute  when  the  container  is  held  two  feet  above  the 
needle.  Leave  the  clamp  thus  adjusted.  When  the  saline  stands  just 
at  the  top  of  the  neck  of  the  container  apply  the  Moore  clamp.  Remove 
the  needle  and  place  in  50  per  cent,  alcohol. 

At  the  right  of  the  patient's  bed  place  all  materials  to  be  used  on  a 
table,  covered  with  a  sterile  towel  and  have  several  small  flat  sterile  pans, 
in  one  of  which  is  50  per  cent,  alcohol. 

n.  Preparation  of  Patient  and  Operator: 

1.  Place  the  patient  as  nearly  flat  as  possible  and  in  bed  so  that  his 
arm  is  near  the  edge  of  the  bed.    Place  the  rubber  sheet  or  newspaper, 
covered  by  a  towel,  under  the  arm. 

2.  Apply  a  tourniquet  to  the  arm  so  that  the  pulse  is  not  decreased 
in  size. 

3.  By  inspection  and  more  especially  by  palpation  determine  the 
largest  and  most  accessible  vein.    The  vein  may  be  made  prominent  by 
the  patient's  opening  and  closing  his  fist  or  by  massaging  the  arm  from 
the  fingers  proximally.    Having  selected  the  vein,  outline  the  centre  of  it 
by  a  thin  line  of  tincture  of  iodine.    Remove  the  tourniquet.    Carefully 


142  TREATMENT  OF  ACUTE  INFECTIOUS  DISEASES 

cleanse  the  skin  over  the  cubital  fossa  with  50  per  cent,  alcohol.  Let  it 
dry  and  then  paint  with  tincture  of  iodine  an  area  of  two  inches  square 
over  the  vein  selected.  Cover  this  sterile  area  with  sterile  gauze  and 
have  someone  hold  the  patient's  arm  still. 

4.  The  operator  now  washes  his  hands  thoroughly  with  soap  and 
water,  followed  by  an  immersion  in  50  per  cent,  alcohol  and  allows  them 
to  dry  naturally.    Put  on  sterile  gloves,  if  available. 

5.  The  completion  of  the  preparation  of  the  patient: 

1.  Have  an  assistant  raise  the  patient's  arm,  protecting  the  sterile 
zone. 

2.  Lay  one  of  the  sterile  towels  under  the  arm ;  lay  arm  on  it. 

3.  Have  assistant  apply  tourniquet  as  before  and  remove  sterile 
gauze  from  arm. 

4.  Lay  one  sterile  towel  over  the  forearm  and  a  second  over  the 
arm,  thus  leaving  the  site  of  injection  exposed. 

5.  Have  assistant  hold  the  patient's  hand  to  prevent  his  moving 
the  arm. 

III.  Pour  the  Serum  Into  the  Container  and  if  a  Kelly  Flask 
is  used,  it  may  be  suspended  from  a  peg  of  a  clothes  tree  or  by  some  other 
device.    Surround  the  flask  with  a  hot  water  bag  or  electric  pad  and  lay 
the  rubber  tubing  in  water  at  110°  F,  taking  precaution  to  retain  the 
sterility  of  the  adapter. 

If  a  funnel  is  used  as  a  reservoir  pour  the  serum  into  it  only  so  fast  as 
to  keep  an  inch  or  two  in  it  and  have  the  pitcher  with  the  bulk  of  the 
serum  sitting  in  the  hot  water.  Be  careful  to  never  allow  the  serum 
to  get  below  the  neck  of  the  funnel  and  thus  admit  air  into  the  tubing. 

Fill  the  hypodermic  syringe  with  the  adrenalin  solution  ready  for  an 
emergency  if  the  patient  should  develop  a  dyspnoea,  cyanosis,  etc. 

IV.  Injection .    With  right  thumb  and  forefinger  grasp  the  butt  of  the 
needle  (avoiding  at  all  times  touching  the  body  of  the  needle) ,  and  with 
the  forefinger  and  thumb  of  the  left  hand,  pinch  up  the  skin  over  the 
vein,  with  a  quick  motion  insert  the  needle  through  the  skin  only.    Now 
steady  the  vein  by  placing  the  forefinger  and  thumb  of  the  left  hand  on 
each  side  of  the  vein  just  above  point  of  puncture.   With  right  hand  hold 
the  needle  at  an  angle  of  about  60°  to  the  vein.    Should  you  fail  to  enter 
the  vein  in  the  first  trial,  withdraw  the  needle  a  short  distance  (but  never 
outside  of  the  skin)  and  repeat  the  attempt,  until  the  blood  flows  freely 
from  the  needle.     Then  quickly  connect  the  adapter  to  the  needle, 
release  tourniquet,  remove  Moore  and  artery  clamp  and  note  the  time 
the  fluid  starts  to  flow.    Observe  the  patient  carefully  for  the  develop- 
ment of  cyanosis,  dyspnoea,  pallor,  urticaria  or  rapid  pulse.     If  any  of 
these  symptoms  develop  interrupt  the  flow  of  serum  for  15  minutes.    If 


PNEUMONIA  143 

they  disappear  continue  the  injection.  If  they  become  worse,  give  a 
hypodermic  injection  of  15  minims  of  adrenalin  and  desensitize  the 
patient  by  Besredka's  method  as  given  above. 

If  no  untoward  symptoms  develop,  after  15  minutes  the  screw 
clamp  is  removed  and  the  remainder  of  the  serum  given  in  15  or  20 
minutes. 

Care  must  be  taken  to  hold  the  needle  steady  and  the  patient  watched 
so  that  he  will  not  break  the  technique. 

When  the  fluid  is  about  gone,  apply  the  Moore  clamp  and  remove  the 
needle  from  the  vein.  Immediately  apply  gentle  pressure  with  gauze 
just  below  the  point  of  entrance  to  avoid  blood  oozing  through  the 
puncture  in  the  vein  into  the  subcutaneous  tissues.  After  a  few  minutes 
remove  the  pressure  and  wash  off  the  iodine  with  95  per  cent,  alcohol  and 
apply  a  small  sterile  pad  over  the  puncture  and  secure  with  a  few  turns  of 
bandage  or  adhesive  straps. 

In  case  a  vein  cannot  be  pierced  with  a  needle  as  described,  cut  down 
on  the  vein.  If  this  is  necessary  one  follows  this  procedure: — apply 
tourniquet,  make  a  one-inch  incision  parallel  to  the  long  axis  of  the  arm, 
starting  at  about  the  middle  of  the  cubital  fossa  and  extending  directly 
downward;  this  will  expose  the  median  basilic  vein,  running  obliquely  in- 
ward. Attempt  to  pierce  the  exposed  vein  with  the  needle;  if  impossi- 
ble, with  a  small  artery  clamp  separate  the  posterior  surface  of  this 
vein  from  the  subcutaneous  tissues  and  insert  beneath  it  a  small  pair  of 
forceps.  With  No.  1  catgut  ligate  the  vein  distal  to  the  forceps.  Pinch 
up  a  small  piece  of  the  centre  of  the  proximal  part  of  the  vein  and  with 
scissors  make  a  minute  snip  in  it.  Insert  immediately  the  cannula  and 
secure  it  firmly  with  a  ligature.  Proceed  as  with  the  needle  method 
above.  When  the  fluid  is  all  in,  apply  the  Moore  clamp  to  the  rubber 
tubing;  remove  the  cannula,  ligate  the  vein  centrally  and  extirpate 
the  portion  between  the  ligatures. 

Remove  any  blood  in  the  wound  with  normal  saline,  close  the  skin 
with  two  catgut  sutures,  paint  with  iodine  and  apply  adhesive  plaster. 

Reaction  after  Serum  Administration.  While  it  is  our  desire 
to  avoid  disagreeable  reactions  after  serum  administrations  and  our 
technique  is  designed  for  that  end,  nevertheless,  certain  reactions  more  or 
less  beyond  our  control  may  ensue.  There  are  three  groups  of  such 
reactions  recognized.  The  first,  a  reaction  that  occurs  during  or  shortly 
after  the  introduction  of  the  serum,  which  is  sometimes  termed  a  non- 
specific serum  intoxication  or  thermal  reaction.  This  reaction  is  accom- 
panied by  much  the  same  phenomena  as  one  witnesses  after  salvarsan 
administration.  In  this  latter  instance  it  is  believed  that  certain  organic 
substances  in  the  distilled  water  used  are  responsible  for  the  reaction 


144  TREATMENT  OF  ACUTE  INFECTIOUS  DISEASES 

and  for  this  reason  the  saline  used  to  dilute  the  serum  should  be  freshly 
prepared  from  freshly  distilled  water,  if  it  can  be  obtained.  Certain 
specimens  of  sera,  perhaps  derived  from  the  same  horse  on  different 
occasions  for  unknown  reasons  may  provoke  the  reaction.  Again  it  is 
said  that  fresh  serum  is  more  likely  to  do  so,  than  serum  properly  ripened. 

Furthermore,  body  temperature  and  slow  administration  seem  to  lessen 
the  incidence  of  these  reactions. 

The  symptoms  may  occur  during  the  administration  or  one  or  two 
hours  later;  they  are  initiated  by  chill,  followed  by  a  high  temperature 
which  in  turn  is  followed  by  an  abrupt  drop,  sometimes  6°-8°  F.,  followed 
by  sweating  and  usually  a  marked  improvement.  It  simulates  a  ma- 
larial paroxysm. 

There  may  be  restlessness,  dyspnoea  and  suffusion  of  the  face  and 
occasionally  vomiting. 

Should  any  of  these  symptoms  appear  during  the  administration  of 
the  serum,  it  should  be  discontinued  an  hour  or  two  and  then  resumed 
and  given  more  slowly. 

To  ameliorate  the  symptoms  one  gives  one-half  c.c.  (m.  vii  of  adrena- 
lin (epinephrin)  intramuscularly  or  atropin  sulphate  gr.  1/100  (0.0006 
Gm.)  by  the  same  method.  This  reaction  has  no  serious  significance  nor 
does  it  militate  against  the  efficiency  of  the  treatment.  It  does,  however, 
alarm  the  practitioner  who  may  fear  that  he  is  facing  a  true  anaphylaxis. 

The  second  group  of  the  reactions  is  the  so-called  serum  sickness  or 
serum  disease,  which  is  a  later  manifestation.  This  ordinarily  occurs 
7-14  days  after  the  serum  injection;  sometimes  as  late  as  a  month.  In 
some  instances  the  reactions  occur  early  in  the  administration  of  the 
serum. 

In  the  early  cases  the  reaction  is  technically  called  an  accelerated 
reaction.  This  reaction  is  in  all  probability  not  an  anaphy lactic  mani- 
festation, but  in  the  period  of  its  development,  the  long  incubation 
period  and  in  its  manifestations,  simulates  the  phenomena  of  certain 
acute  infectious  diseases,  for  example,  measles  and  scarlet  fever.  It 
happens  to  some  degree  in  about  50  per  cent,  of  the  cases;  it  is  rarely 
severe  and  never  leaves  any  sequelae.  The  symptoms  are  a  mild  eleva- 
tion of  temperature,  at  times  to  103°  F.,  skin  rashes,  of  which  the  urticaria 
is  the  most  characteristic  and  annoying,  sometimes  angioneuretic  edema, 
although  the  eruption  may  be  macular  or  erythematous ;  joint  involve- 
ment is  frequent  enough.  It  simulates  a  mild  or  moderately  severe  at- 
tack of  articular  rheumatism,  in  which,  it  will  be  recalled,  similar  skin 
rashes  occur.  Albumin  may  appear  in  the  urine,  but  one  need  not  look 
upon  this  as  a  serious  kidney  involvement.  The  discomforts  of  the 
urticaria  may  be  relieved  by  the  usual  methods;  bathing  in  soda  solu- 


PNEUMONIA  145 

tions  in  varying  strengths,  application  of  aqueous  solutions  of  phenol 
(carbolic  acid)  1-2  per  cent,  or  phenol  in  olive  oil,  or  vaseline  5-10  per 
cent.,  while  in  some  instances  adrenalin  given  intramuscularly  in  doses 
of  one-half  to  one  c.c.  (m.  vii-xv)  seems  efficacious. 

The  third  group  of  reactions  are  those  which  are  attributed  to  the 
condition  of  sensitization  described  above  and  most  commonly  termed 
anaphylaxis. 

As  it  was  explained  that  this  condition  was  due  to  the  introduction  of 
foreign  protein  into  the  tissues,  it  is  understood  that  previous  adminis- 
tration may  in  some  instances  induce  a  greater  or  less  degree  of  this 
sensitLzation.  Fortunately,  however,  in  the  human  being  this  rarely  in- 
duces the  most  severe  reaction  called  anaphylactic  shock.  Shock  is  more 
likely  to  occur  in  individuals  sensitized  to  horse  emanations,  especially 
in  those  in  whom  this  sensitization  expresses  itself  as  asthma,  hence  the 
very  great  importance  of  determining  the  presence  or  absence  of  such 
attacks  in  every  patient  to  whom  serum  is  to  be  administered. 

It  has  already  been  described  how  such  patients  can  be  desensitized. 
Anaphylactic  shock  occurs  during  the  administration  or  immediately 
after  and  is  recognized  by  the  suffusion  of  the  face,  the  profound  restless- 
ness, shortness  of  breath  and  rapid  heart  or  by  pallor  with  symptoms  of 
collapse.  Sometimes  the  symptoms  of  shock  occur  after  the  adminis- 
tration, but  usually  fairly  promptly.  Adrenalin  (epinephiin),  1-1000 
intramuscularly,  in  doses  of  15  minims  (1  c.c.)  should  be  given  at  once. 
If  the  pulse  is  soft  and  the  blood  pressure  low,  strophanthin,  J/£  milli- 
gram (gr.  1/120)  intravenously,  or  digitalis  in  some  of  its  forms  equiva- 
lent to  3  to  5  grains  (0.2-0.33  Gm.)  of  the  drug,  e.  g.,  tincture  diluted 
with  saline  two  or  three  times,  digitoxin  gr.  1/100  to  1/60  (0.0006-0.001 
Gm.)  in  m.  xv  (1.0  c.c.)  of  alcohol  diluted  four  times  with  saline,  or  so- 
lutions of  properly  assayed  commercial  preparations,  should  be  given 
intravenously.  Heat  should  be  applied  to  the  extremities,  hot  towels  laid 
across  the  abdomen,  in  other  words  treated  as  shock. 

If,  as  commonly  occurs,  intense  asthma  is  the  dominant  feature  of  the 
reaction,  adrenalin  in  doses  of  15-30  minims  (1-2  c.c.)  should  be  given 
intramuscularly,  atropin  gr.  1/50  (0.0012  Gm.)  intramuscularly,  mor- 
phine sulphate  gr.l  /8  to  1/4  (0.008-0.015  Gm.)  subcutaneously  or  intra- 
muscularly. If,  in  spite  of  these  measures,  cyanosis  deepens  and  the 
dyspnoea  increases,  it  must  be  recalled  that  the  air  vesicles  are  over  dis- 
tended and  unable  to  empty  themselves  of  air.  It  would  be  logical  to 
express  the  air  by  force.  This  may  be  done  by  encircling  the  chest  with 
one's  arms  and  expressing  the  air  rhythmically.  This  I  have  seen  done  in 
one  instance  with  the  most  satisfactory  results. 

If  everything  goes  well,  within  an  hour  or  two  after  the  administration 


146          TREATMENT  OF  ACUTE  INFECTIOUS  DISEASES 

of  the  serum  there  is  a  slight  rise  of  temperature,  followed  by  a  marked 
fall,  the  patient's  mental  condition  is  improved,  the  heart  rate  is  slower 
and  the  respiration  is  slower  and  less  labored.  Furthermore  the  blood 
stream  is  rendered  free  from  organisms,  unless  there  was  a  marked 
septicemia;  arid  the  process  in  the  lung  may  be1  arrested.  To  what  these 
changes  are  due,  we  have  no  adequate  explanation.  We  know  that  the 
power  of  agglutination  is  markedly  increased  and  that  the  pneumococci 
are  more  susceptible  to  phagocytosis,  due  to  the  increased  production 
of  opsonins. 

Frequency.  We  repeat  the  serum,  if  after  an  interval  of  8-10  hours 
there  is  a  secondary  rise  of  temperature  with  an  increase  in  the  symptoms 
of  the  disease,  or  we  repeat  the  injections  after  this  interval  if  there  has 
been  no  improvement  in  the  condition. 

Dosage.  The  usual  dosage  is  60-100  c.c.  As  the  serum,  unlike  drugs, 
has  no  toxic  effects,  the  dosage  is  determined  by  what  in  practice  has 
been  found  sufficient  and  by  the  limitation  of  expense.  Larger  doses 
therefore  would  be  indicated  in  the  more  toxic  stages.  In  the  severe 
cases  the  interval  between  doses  is  usually  8  hours  or  less.  In  the  cases 
showing  improvement,  the  physician's  judgment  must  determine  the 
interval.  As  the  disease  advances  it  has  been  found,  that  larger  and 
larger  doses  are  required  to  get  equivalent  results. 

The  general  principles  of  therapy  applicable  to  the  one  form  are  also 
applicable  to  the  other.  Certain  details  of  one  or  the  other  form  of 
pneumonia  may  demand  modifications  or  differences  in  treatrnent. 
These  will  be  considered. 

Rest.  First  of  these  in  importance  is  rest.  Rest  means  rest  in  bed  in 
a  quiet  environment.  When  the  patient  is  very  sick  it  means  avoidance 
of  every  muscular  effort,  even  turning  in  bed  being  done  by  the  nurse  or 
attendant;  use  of  the  bed-pan  and  urinal;  absolute  interdiction  of  the 
effort  to  arise  to  attend  to  these  matters.  Twice  I  have  witnessed  edema 
of  the  lungs  precipitated  by  the  act  of  turning  the  patient  for  purposes  of 
examination.  In  very  sick  patients  as  infrequent  examination  of  the 
chest  as  is  compatible  with  an  appreciation  of  the  progress  of  the  disease 
is  desirable.  Rest  means  competent  nursing;  it  means  freedom  from 
worry,  anxiety,  introduction  of  business  cares  and  concerns;  it  means 
the  exclusion  of  all  visitors  and  of  all  individuals  who  are  not  concerned 
in  the  care  and  comfort  of  the  patient. 

Bed.  Rest  in  bed  is  rest  only  when  the  bed  is  comfortable.  The 
type  of  bed  is  best  illustrated  by  the  hospital  bed.  It  is  a  half  or  at  most 
three-quarters  bed  with  a  firm  woven  wire  spring,  and  a  firm  but  resilient 
mattress.  The  bed-clothes  must  be  applied  smoothly  and  without 
wrinkles;  the  clothes  upon  the  patient  chosen  to  avoid  excess  of  weight 


PNEUMONIA  147 

and  should  be  no  more  than  afford  maximum  comfort  to  the  patient- 
only  one  pillow  should  be  used.  For  purposes  of  cleanliness  as  well  as 
comfort  a  rubber  sheet  should  be  placed  across  the  bed.  The  width  of 
this  sheet  should  be  such  as  to  reach  from  the  pillow  to  the  bend  of  the 
patient's  knees  and  sufficiently  long  to  tuck  under  the  mattress  nicely. 
Over  this  sheet  should  be  placed  a  draw-sheet,  a  long  sheet  folded  length- 
wise with  width  enough  to  cover  the  rubber  sheet  and  so  long  that  it  may 
be  drawn  from  the  one  side  to  the  other  from  time  to  time  to  bring  a  cool 
surface  to  the  patient's  body  or  to  remove  a  soiled  spot. 

During  the  period  of  convalescence  when  the  patient  is  allowed  a  bed 
rest,  the  inevitable  tendency  to  slide  in  the  bed,  costs  the  patient  much 
energy. 

One  may  have  recourse  to  the  device  of  placing  a  rolled  blanket  under 
the  knees  or  between  the  feet  and  the  foot  of  the  bed  as  a  support. 
Numerous  foot  rests  have  been  devised  for  this  purpose,  but  none  are 
satisfactory.  A  bed  whose  frame  is  so  devised  as  to  be  raised  at  its  upper 
end  to  afford  a  back  rest  and  at  a  point  corresponding  to  the  patient's 
knees  to  give  support  to  the  flexed  limbs,  is  in  my  estimation,  by  far  the 
most  satisfactory  device.  This  type  of  bed  is  illustrated  by  the  Gatch 
bed. 

Room.  The  room  should  be  chosen  with  reference  to  sufficiency  of 
light  and  air. 

It  should  be  stripped  of  all  unnecessary  furniture;  if  possible,  it  should 
be  so  near  the  bathroom  as  to  facilitate  the  many  demands  of  nursing. 

Even  better  is  a  room  from  which  a  verandah  or  porch  may  be  ap- 
proached, on  to  which  the  patient  may  be  wheeled,  if  necessary. 

Temperature  of  the  Room.  This  should  be  about  65°  F.  unless  the 
patient  is  submitted  to  cold  air  treatment.  At  whatever  temperature  the 
room  is  kept,  the  patient  should  be  so  placed  as  to  avoid  drafts. 

Care  of  the  Body.  The  care  of  the  body  is  of  prime  importance 
as  it  means  comfort  to  the  patient  and  a  more  efficient  performance  of 
important  functions.  This  is  the  particular  province  of  the  nurse,  but 
when  a  nurse  cannot  be  in  attendance  it  is  the  business  of  the  physician 
to  explain  the  details  to  whomsoever  is  to  act  as  nurse,  of  all  that  con- 
stitutes the  proper  care  of  the  body. 

Bath.  A  sponge  bath  should  be  given  for  purposes  of  cleanliness,  as 
well  as  comfort  every  day.  The  only  excuse  for  omission  of  the  bath  is 
such  a  weakened  condition  on  the  part  of  the  patient  that  even  the  little 
manipulation  concerned  in  it  becomes  to  him  a  source  of  exhaustion  and 
danger. 

The  temperature  of  the  room  when  the  bath  is  given  should  be  from 
65°  F.  to  70°  F.  If  this  can  not  be  effected  the  bath  may  be  given  be- 


148  TREATMENT  OF  ACUTE  INFECTIOUS  DISEASES 

tween  blankets.  Tepid  water  and  castile  soap  are  used  and  the  skin 
gently  wiped  or  dabbed  dry  with  a  towel. 

Special  attention  should  be  given  to  the  eyes,  the  ears,  the  parts  of 
the  body  most  pressed  upon  and  likely  to  become  the  seat  of  bed-sores; 
the  genitals  and  the  anus. 

Mouth.  The  care  of  the  mouth  is  of  great  importance,  especially  in 
early  toxic  cases,  when  the  patient  is  stuporoiis  or  comatose,  the  mouth 
dry,  the  tongue  coated,  the  lips  and  teeth  covered  with  sordes  and  in 
these  cases  secondary  infection  affecting  the  parotid  gland  and  the 
middle  ear  and  possibly  complicating  bronchi  and  lungs  with  secondary 
invasion,  as  well  as  imperilling  the  digestive  tract,  are  to  be  constantly 
kept  in  mind. 

In  all  cases  the  mouth  should  be  rinsed  after  each  feeding  with  some 
mild  antiseptic  solution,  such  as  a  saturated  solution  of  boric  acid,  4  per 
cent,  or  half-saturated  solution,  2  per  cent,  or  one  may  use  DobelTs 
solution,  }/2  or  J4  strength. 

The  teeth,  too,  should  receive  attention.  The  interstices  freed  from 
particles  of  food  that  may  undergo  decomposition.  The  best  way  to  do 
this  is  to  use  closely  rolled  swabs  of  absorbent  cotton  on  wooden  tooth- 
picks; these  being  wet  with  the  solutions  named.  A  soft  tooth  brush 
may  be  used,  but  care  has  to  be  exercised  to  avoid  trauma  of  the  gums  or 
lips. 

Tongue.  When  the  tongue  is  much  coated  and  when  there  is  sordes 
upon  the  teeth  or  lips,  half-strength  solution  of  peroxide  of  hydrogen 
should  be  applied  to  soften  the  deposit  and  the  excess  scraped  away 
with  the  edge  of  a  whalebone  or  similar  instrument  and  then  the  tongue 
and  lips  should  be  cleansed  with  the  above  solution.  For  a  very  dry 
mouth  a  mixture  of  equal  parts  of  liquid  petrolatum  (albolene)  and  2 
per  cent,  boric  acid  solution  flavored  with  lemon  juice  is  an  excellent 
application.  When  the  breath  is  fetid  or  there  is  much  stomatitis  an 
application  of  an  antiseptic  solution  as  follows  is  excellent : 

Phenol  (Carbolic  Acid)  watery  solution  1-20 ._. 

Glycerin aa  5i  (30  c.c.) 

Boric  Acid,  saturated  watery  solution 5viii        (240  c.c.) 

M. 

S.    Use  as  directed. 

Collections  of  mucus  in  the  naso-pharynx  and  the  back  of  the  mouth 
are  best  removed  with  cotton  swabs  on  long  applicators,  which  have  been 
saturated  with  some  of  the  mild  antiseptic  solutions. 

Gargles  do  not  reach  back  to  the  naso-pharynx  and  rarely  reach  the 
tonsil.  The  back  of  the  mouth,  then,  should  be  cleansed  by  the  use  of  a 
spray,  the  tongue  being  depressed  with  an  applicator,  while  the  spray  is 


PNEUMONIA  149 

used.  A  boric  acid  solution  or  a  Dobell's  solution  may  be  used  fop 
this  purpose. 

Nose .  Attention  also,  should  be  given  to  the  nose ;  for  if  this  is  plugged 
with  secretions,  the  patient  is  obliged  to  breathe  through  the  mouth  and 
the  dryness  of  the  mouth  and  coated  tongue  is  aggravated.  Dried 
secretions  should  be  softened  by  the  application  of  vaseline  or  sweet  oil 
and  then  the  nose  is  cleansed  with  a  cotton  swab  on  a  toothpick  or 
other  applicator,  which  has  been  saturated  in  one  of  the  solutions 
mentioned. 

Sprays,  too,  may  be  used.  Irrigations  should  be  avoided,  lest,  espe- 
cially if  the  patient  is  somewhat  stuporous,  the  solutions  are  forced  into 
the  Eustachian  tube,  carrying  with  them  infection. 

Fissures  and  herpetic  eruptions  should  be  treated  with  the  solu- 
tions and  then  anointed  with  the  oil  or  vaseline  (petrolatum) . 

Eyes  are  to  be  kept  clean  by  the  use  of  half  strength  or  saturated 
boric  acid  solution. 

Care  of  the  genitals  requires  a  careful  cleansing  after  every  defecation 
and  in  the  female  after  micturition.  The  same  solutions  may  be  used  for 
this  purpose.  If  there  are  excoriations  a  carbolic  acid  solution  %  per 
cent,  to  1  per  cent,  may  be  used,  then  the  parts  are  to  be  kept  dry  and 
dusting  powder  applied  to  the  skin  about  the  parts. 

Diet.  The  dietetic  demands  are  quite  different  in  the  acute  lobar 
pneumonias,  of  short  course,  marked  by  much  intoxication,  and  the 
longer  continued  broncho-pneumonias  or  the  unresolved  pneumonias  or 
pneumonias  with  complications  that  prolong  the  course,  for  a  consider- 
able period  of  time. 

The  impairment  of  digestion  and  assimilation  is  much  less  than  is 
usually  assumed.  Such  impairment  as  there  is  lasts  only  during  the  early 
hours,  the  first  day  or  two,  of  an  acute  process  or  when  the  intoxication 
is  very  intense.  During  this  time  there  is  often  gastric  distress  and 
usually  anorexia.  It  is  better  at  this  time  not  to  force  the  food,  but 
after  this  period  has  passed  certain  theoretical  considerations  have  to  be 
kept  in  mind.  These  are  that  a  man  at  rest,  suffering  from  an  infectious 
process  expends  as  much  energy  as  a  well  man  at  rest,  but  in  addition 
to  this  the  febrile  process,  when  the  temperature  is  above  102°  F.  or 
102.5°  F.,  increases  the  need  of  food  intake  some  25  per  cent. 

These  two  requirements  amount  to  about  forty  calories  per  kilo 
of  body  weight  or  some  2,800  to  3,000  calories  for  the  adult  male  of 
average  weight;  but  in  addition  to  this  the  acute  infection  induces  a 
protein  loss  that  can  be  prevented  only  by  increasing  the  food  intake  even 
above  the  amounts  already  mentioned.  No  amount  of  protein  intake  will 
make  good  for  this  protein  loss  unless  a  sufficiency  of  carbohydrate 


150          TREATMENT  OF  ACUTE  INFECTIOUS  DISEASES 

should  be  administered  with  the  protein.  Under  these  circumstances 
protein  intake  of  from  seventy  to  ninety  grams  are  sufficient. 

We  rely  particularly  upon  milk.  One  quart  of  milk  gives  about 
640  calories  or  about  twenty  calories  to  the  ounce.  It  is  obvious,  how- 
ever, that  if  we  were  to  use  milk  alone  the  quantity  necessary  to  supply 
the  number  of  caloiies  required  would  be  inordinate.  It  becomes  neces- 
sary, then,  to  add  other  articles  of  food,  which  have  a  high  calorie  con- 
tent and  a  low  protein  content.  One  of  the  simplest  means  of  obtaining 
such  a  result  is  to  add  cream. 

Gravity  cream,  16  per  cent,  cream,  affords  about  fifty  calories  to  the 
ounce.  Milk  sugar  is  another  substance  that  can  be  added  to  the  milk, 
each  ounce  giving  120  calories. 

A  half  ounce  of  milk  sugar  and  one  ounce  of  gravity  cream  added  to 
each  glass  of  milk  increase  the  calorie  content  a  little  over  one  hundred. 
Other  substances  that  may  be  added  are  cereals,  such  as  thoroughly 
cooked  oatmeal,  or  hominy  or  rice;  an  ordinary  serving  of  these  articles 
of  food,  varying  from  three  to  five  ounces,  according  to  the  nature  of  the 
cereal  adds  another  one  hundred  calories.  When  cream  and  sugar  are 
added  to  such  a  serving,  the  calorie  content  is  greatly  increased;  as  two 
ounces  of  cream  and  three  teaspoonfuls  of  granulated  sugar  offer  each  an 
additional  one  hundred  calories. 

One  may  give  eggs,  raw  or  soft  cooked.  A  coddled  egg,  that  is,  an 
egg  which  is  put  into  boiling  water  and  then  set  aside  from  the  stove  and 
allowed  to  cook  as  the  water  cools  for  five  minutes  thus  acquiring  a 
creamy  consistency  makes  an  excellent  addition  to  the  dietary;  eggs  and 
milk  in  the  shape  of  cup  custard,  broths  made  of  cereals  and  milk;  bread 
given  as  toast  or  as  milk  toast  or  plain  bread  and  butter,  all  add  mate- 
rially. 

Various  milk  preparations  may  be  used  in  place  of  milk,  such  as 
matzoon,  koumys,  zoolak,  buttermilk. 

If  the  patient's  appetite  craves  them,  meat  soups,  mutton  broth  or 
chicken  broth  may  be  given,  but  it  must  be  remembered  that  they  have 
very  little  food  value  hence  rice  or  other  cereal-flour  may  be  cooked  into 
them  to  give  them  some  caloric  value. 

If  tympanites,  often  an  early  symptom  of  the  disease,  is  increased 
out  of  proportion  to  the  other  evidences  of  the  intoxication,  one  should 
suspect  the  milk  sugar  as  being  responsible. 

If  diarrhea  ensues  one  cuts  down  the  fat;  while  both  fat  and  sugar  may 
be  responsible  for  gastric  distress  and  vomiting.  Under  these  circum- 
stances these  elements  must  be  cut  out  until  the  symptoms  disappear 
and  then  gradually  replaced. 

In  a  lobar  pneumonia  of  short  course,  then,  we  give  an  abundance 


PNEUMONIA  151 

of  water  in  the  early  days,  with  small  amounts  of  milk.  If  the  stomach 
be  irritable,  this  milk  had  better  be  diluted  either  with  plain  water,  an 
alkaline  water  or  with  cereal  water.  The  food  is  gradually  increased,  but 
no  effort  is  made  to  reach  a  high  calorie  diet;  but  in  prolonged  pneumo- 
nias, broncho-pneumonias,  unresolved  pneumonias  and  complicated 
pneumonias,  one  treats  them  much  as  he  would  a  typhoid  fever  case. 

Drinks.  Water  is  rarefy  given  in  sufficient  quantities.  It  ought  to  be 
offered  to  the  patient  every  hour  or  two  and  this  particularly  as  the 
patient  is  often  so  stuporous  as  not  to  ask  for  water  that  he  sorely  needs. 
It  is  surprising  to  see  how  much  these  patients  will  take  when  the  water 
is  offered  them.  It  unquestionably  affords  a  stimulus  to  diuresis,  and 
diaphoresis  and  keeps  the  bowels  in  better  condition,  lessens  tympanites, 
keeps  the  tongue  and  mouth  moister  and  is  in  every  way  beneficial. 

Fruit  juices,  lemonade,  orangeade,  Imperial  drink  can  be  given  as 
freely  as  water  and  these  latter  afford  an  excellent  means  of  conveying 
sugar  which  increases  the  food  intake. 

Two  to  three  quarts  of  fluid  a  day  should  be  given  and,  if  the  patient 
will  take  more,  three,  four  or  five  willingly,  he  should  be  allowed  it. 

Care  of  the  Bowels.  Attention  to  the  bowels  in  pneumonia 
is  almost  as  imperative  as  in  typhoid  fever;  for  tympanites  is  almost  as 
common  in  the  one  as  in  the  other.  The  toxins  of  pneumonia  affect  the 
large  bowel  and  its  motility  characteristically;  a  moderate  grade  of 
paresis  of  the  colon  obtains  in  a  very  large  per  cent,  of  the  cases,  occur- 
ring early  in  the  course  of  the  pneumonia. 

The  danger  that  accrues  to  this  condition  is  entailed  by  the  displace- 
ment of  the  diaphragm  upward  with  consequent  encroachment  on  the 
thoracic  space,  favoring  congestion,  hypostatic  pneumonia  and  lessening 
the  respiratory  excursion  of  the  already  impaired  lung. 

The  heart,  too,  undergoes  a  certain  degree  of  displacement  by  the 
crowding  upward  of  the  diaphragm  and  its  operation  is,  consequently, 
made  more  difficult. 

Stasis,  too,  in  the  large  intestine  favors  fermentation  which  in  turn 
aggravates  the  tympanites  and  permits  of  absorption  of  products  of 
decomposition  and  putrefaction  which  add  their  own  increment  of  insult 
to  the  already  toxic  organism.  . 

When  the  case  is  first  seen,  then,  a  catharsis  of  calomel  or  salts 
should  be  given.  Three-quarters  of  an  ounce  to  an  ounce  (20-30 
Gm.)  of  Rochelle  salt  or  Epsom  salt  or  (and  particularly  if  there  be  any 
nausea)  small  doses  of  calomel;  for  example,  grain  1/4  (0.015  Gm.)  every 
1/4  hour  until  six  or  eight  are  taken  or  in  children  gr.  1/10  (0.006  Gm.) 
every  ten  minutes  until  one  grain  is  taken  and  this  followed  in  three  or 
four  hours  by  a  half  ounce  (15  Gm.)  of  one  of  the  salts  mentioned  in  a 


152  TREATMENT  OF  ACUTE  INFECTIOUS  DISEASES 

half  to  three-quarters  of  a  glass  of  water.  Later  it  is  better  to  rely  on 
the  enema  to  keep  the  bowel  in  condition;  or  one  may  give  liquid  petro- 
latum in  tablespoonful  doses  or  more  if  needed  to  effect  the  result  al- 
though there  is  no  objection  to  the  use  of  salts  for  the  same  purpose 
occasionally. 

Tympanites.  This  symptom,  because  of  the  danger -it  entails, 
must  receive  attention.  It  is  less  marked  in  those  cases  that  have  a 
sufficiency  of  water  given  them. 

The  diet,  too,  should  be  inspected  with  reference  to  the  quantity 
of  fats  or  milk  sugar  it  contains,  either  of  which  may  be  responsible 
in  some  measure  for  the  collection  of  gases,  and  should  be  diminished 
or  eliminated  from  the  dietary. 

The  enemata  themselves  offer  much  relief  and  their  effects  are  en- 
hanced by  the  addition  of  small  quantities  of  the  oil  of  turpentine. 

1  use  5ss.-gi  (15-30  c.c.)  of  turpentine  in  a  pint  of  soapsuds.  One  makes 
a  thick  lather  with  castile  soap  and  a  small  amount  of  water,  stirs  in 
slowly  the  amount  of  turpentine  to  be  used  and  then  adds  water  up  to  a 
pint  or  more  if  desired.    In  this  way  the  turpentine  is  kept  in  emulsion. 
Other  enemas  for  the  same  purpose  that  may  be  found  effectual  are, 

2  teaspoonfuls  of  the  essence  of  peppermint  to  2  quarts  of  warm  saline  or 
5ss.  (2  c.c.)  of  tincture  of  asafoetida  in  2  quarts  of  normal  saline  or  tap 
water.    A  very  excellent  enema  to  relieve  tympanites,  to  which  the  sur- 
geon often  has  recourse,  is  made  of  milk  and  molasses,  using  a  cupful, 
(200-250  c.c.)  of  each.    One  warms  the  molasses  until  its  consistency  is 
thinned  and  adds  warm  milk,  the  temperature  being  above  body  temper- 
ature.   It  is  best  given  with  a  funnel  and  tube. 

Rectal  Tubes  may  also  be  inserted,  just  as  in  typhoid  fever. 

Shattuck  speaks  enthusiastically  of  the  efficiency  of  pure  glycerin 
in  doses  of  one  to  two  ounces  (30-60  c.c.)  by  rectum  for  the  relief  of 
tympanites. 

Stupes,  too,  are  to  be  used  for  this  purpose;  for  the  technique  see 
Typhoid  Fever,  Chap.  XIV. 

Turpentine  may,  also,  be  given  by  way  of  the  mouth  in  capsules, 
of  5  to  10  minims  (0.30-0.60  c.c.)  each  or  in  an  emulsion.  The  disa- 
greeable taste  may  be  covered  by  adding  a  suitable  amount  of  cinnamon 
or  some  other  aromatic  substance. 

Strychnine  for  its  tonic  effect  on  the  musculature  of  the  bowel  may  be 
used  in  doses  of  gr.  1/30  (0.002  Gin.)  three  or  four  times  a  day. 

Pituitrin  or  pituitary  extract  which  contracts  the  smooth  muscle 
substance  of  the  intestine  often  acts  happily  in  this  condition,  but  the 
results  are  not  always  certain.  As  the  drug  is  credited  with  a  stimulating 
effect  upon  blood  pressure,  no  harm  will  come  from  its  use,  except  in  the 


PNEUMONIA 


153 


Murphy  Drip  Apparatus 


Glass  tube  for 
air   vent 


Murphy   drip  or 
Calcium  Chloride  bulb 

Rubber   tubing  


Suspension  hook 
Adhesive  tapes 

Thermos  bottle 

Rubber  stopper 
Short  glass  tube 

Rubber  tubing 
Screw  clamp 


Glass  tube 


#16  French  Catheter 


154  TREATMENT  OF  ACUTE  INFECTIOUS  DISEASES 

case  of  pregnant  women.  The  usual  dose  is  1  c.c.  of  the  extract  hypoder- 
mically,  which  may  be  obtained  in  the  various  pharmaceutical  houses. 
A  failure  to  accomplish  the  desired  result  may  be  due  to  the  poor  quality 
of  the  preparation  used  and  should  not  discourage  one  from  further  trial 
of  another  preparation. 

A  Murphy  drip,  with  the  bag  held  about  a  foot  above  the  bed  may 
be  used  for  the  same  purpose.  The  temperature  of  the  saline  used 
should  be  about  that  of  the  body  or  slightly  above,  and  the  solution  may 
be  kept  warm  in  the  bag  by  applying  hot  water  bottle  about  it  or  insert- 
ing an  electric  bulb  in  it.  Even  a  better  method  for  maintaining  temper- 
ature of  the  drip  is  a  thermos  bottle.  One  should  remember  that  the 
radiation  of  heat  as  the  solution  passes  through  a  long  tube  is  excessive. 
It  is  the  temperature  of  the  solution  as'  it  enters  the  bowels  that  we 
are  concerned  with;  short  tubes  of  large  calibre  or  protection  of 
the  tube  by  allowing  it  to  rest  in  hot  water  are  devices  to  subserve 
this  end. 

The  apparatus  needed  for  the  administration  of  Murphy  drip  is 
simple;  it  consists  of: 

1.  A  container  for  the  fluid. 

2.  Two  feet  rubber  tubing  5  mm.  in  diameter. 

3.  Number  16  French  cathether  or  plain  rubber  tip  of  an  ordinary 
douche  bag. 

4.  Screw  clamp  or  artery  clamp. 

5.  Glass  coupling  like  one  of  the  illustrations,  or  a  Murphy  drip  bulb 
or  calcium  chloride  bulb. 

The  simplest  container  to  use  is  a  thermos  bottle,  as  it  maintains  the 
water  at  the  desired  temperature  for  a  long  time.  However,  one  can  use 
any  ordinary  bottle  that  will  hold  a  pint  to  a  quart.  The  neck  of  the 
bottle  is  filled  with  the  two-hole  stopper,  carrying  two  pieces  of  glass 
tubing,  one  being  so  short  that  it  is  just  flush  with  the  inner  end  of  the 
stopper  and  the  other  extending  to  the  bottom  of  the  bottle  and  pulled 
out  to  a  capillary.  To  the  outer  end  of  the  short  tube  is  attached  the 
rubber  tubing,  which  is  connected  with  the  glass  coupling  which  in  turn 
is  joined  to  a  No.  16  French  catheter.  Now  insert  the  French  catheter 
6"  into  the  rectum  and  start  the  water  flowing  at  the  rate  of  30  drops  a 
minute  into  the  glass  coupling,  controlling  the  flow  by  a  screw  clamp 
or  artery  clamp.  The  water  should  be  about  105°  F-1080  F.  as  it  enters 
the  rectum .  If  the  thermos  is  no  t  used  one  may  use  an  electric  pad  or  hot 
water  bottle  around  the  container.  The  flow  should  be  at  such  a  rate 
that  the  desired  amount  of  fluid  will  be  given  in  24  hours,  30  drops  per 
minute  running  continuously  will  deliver  about  5.5  pints  in  24  hours. 
(See  diagram  of  apparatus.) 


PNEUMONIA 

The  container  should  hang  not  more  than  18  inches  above  the  rectum 
of  the  patient. 

The  patient  should  be  in  a  recumbent  or  semi-recumbent  position. 

The  solution  used  may  be  a  0.5  per  cent,  salt  solution,  or  a  3  pei  cent, 
sodium  bicarbonate  with  5  per  cent,  glucose  in  either  solution. 

The  rate  depends  on  the  amount. 

Symptomatic  Treatment.  Before  touching  upon  the  individual 
symptoms  I  will  mention  those  measures  which  enhance  the  functions 
of  the  body  as  a  whole,  that  increase  its  powers  of  resistance. 

The  Open-Air  Treatment.  I  am  convinced  that  there  is  no 
measure  comparable  in  its  effects  on  the  vital  centres  to  fresh,  live  air 
in  the  open. 

The  open  air  to  have  its  stimulating  effect  or  to  have  its  maximum 
stimulating  effect  must  be  cold  and  dry  and  in  motion.  The  constant 
play  of  the  currents  of  cold  dry  air,  impinging  on  the  nerve  endings  of  the 
face  and  the  upper  air  passages  send  their  impulses  to  the  vaso-motor, 
respiratory  and  other  vital  centres  acting  upon  them  as  stimulants. 

Fresh  air,  alone,  desirable  as  it  may  be,  such  as  one  gets  by  having  the 
windows  of  a  room  or  ward  open  does  not  give  the  same  results  as  the 
air  out-of-doors. 

As  the  temperature  rises  and  as  the  humidity  increases  the  effects 
of  the  open  air  diminish. 

Sufficient  reports  have  been  made,  and  my  own  observations  have 
confirmed  them,  to  assure  us  that  as  measured  by  the  improvement  in 
blood  pressure  there  is  no  drug  classed  as  a  circulatory  stimulant,  the 
effects  of  which  are  so  decided,  so  sustained,  as  the  effects  of  fresh  air. 

Not  only  does  the  pulse  show  a  better  quality  and  become  slower, 
but  the  respiratory  act  is  deepened,  the  nervous  manifestations  les- 
sened, cyanosis  is  diminished,  and  the  patient  in  every  way  shows 
improvement. 

However,  to  effect  the  desired  results,  a  technique  is  to  be  carefully 
observed.  The  preparation  of  the  bed  and  the  patient  in  the  bed  is  all 
important. 

When,  as  is  usual,  a  patient  in  this  treatment  is  exposed  to  the  winter 
air,  our  effoi  ts  are  directed  against  any  possible  chilling  of  the  surface  of 
the  body  and  extremities;  for  if  this  occurs  our  efforts  are  defeated  and 
our  patients  may  be  truly  endangered. 

The  Bed.  A  half  bed,  preferably  of  the  hospital  type,  is  stripped 
to  the  woven  wire  spring.  Upon  these  springs  is  spread  a  large  blanket, 
extending  well  beyond  the  sides  of  the  bed  and  well  beyond  the  foot. 
Upon  this  blanket  is  laid  rubber  sheeting  or  thick  papers,  that  extend 
beyond  the  sides  and  foot  as  far  as  the  blanket  does.  Upon  these  papers- 


156  TREATMENT  OF  ACUTE  INFECTIOUS  DISEASES 

is  laid  the  mattress  and  then  the  bed  is  made  in  the  usual  way  with  every 
care  for  the  smoothness  of  the  sheet  and  the  draw  sheet. 

The  patient,  prepared  as  presently  to  be  mentioned,  is  placed  in  this 
bed  and  then  the  blanket  and  the  rubber  shee,t  within  it  are  drawn  up 
around  the  mattress,  bed  and  patient  in  such  a  way  as  to  form  a  complete 
envelope  and,  in  fact,  folded  much  as  one  would  an  envelope,  u 

The  patient  has  been  in  the  meantime  clad  in  an  under  suit  of  flannel, 
with  stockings,  and  a  hot  water  bottle  is  placed  at  the  feet.  Upon  his 
head  is  a  hood;  only  his  face  is  left  exposed.  One  low  pillow  is  afforded 
him.  If  there  be  high  winds,  an  effort  should  be  made  at  affording  a 
shelter  by  the  use  of  screens  or  the  position  of  the  bed;  while  some 
shelter  to  the  head  can  be  procured  by  the  use  of  pillows  on  either  side  of 
the  head,  making  an  inverted  letter  V.  The  object  of  all  this  is  to  prevent 
air  getting  at  the  patient's  skin  to  chill  him. 

The  patient  must  be  kept  under  constant  observation,  and  more 
particularly  if  he  is  in  any  degree  delirious,  lest  he  disarrange  his  clothes 
and  become  chilled  or  lest  in  his  delirium  he  leave  his  bed  and  injure 
himself. 

Nurses  and  attendants  must  be  clad  for  out-of-doors. 
For  purposes  of  examination  the  patient  should  be  drawn  into  the 
room  and  the  temperature  of  the  room  raised  to  65°  F.  or  70°  F.  before  he 
is  exposed ;  and  the  same  precaution  should  be  taken  when  the  bed-pan 
or  the  urinal  is  to  be  used  or  the  toilet  of  the  body  performed. 

When  the  conveniences  are  not  at  hand  for  such  a  treatment,  on 
the  verandah  or  the  porch  or  fire-escape  or  roof,  one  substitutes  for  this 
treatment  a  room,  the  windows  of  which  are  wide  open  or  the  sash  taken 
out,  the  window  space  being  filled  with  cheese-cloth  screens. 

It  is  common  to  see  a  rise  of  blood-pressure  of  10-20  mm.  Hg.,  or 
even  more,  shortly  after  the  patient  leaves  the  ward  or  room.  This 
will  persist  until  he  is  brought  back  into  the  ward  and  it  is  certainly 
curious,  as  well  as  interesting  that,  although  the  ward  or  room,  into 
"which  he  is  brought  is  thoroughly  ventilated,  the  blood  pressure  will 
gradually  go  down  several  mm.  after  he  has  been  taken  from  the  open 
air.  It  has  been  objected  that  patients  with  a  severe  cough  find  the 
cough  exaggerated  by  the  exposure  to  cold  air.  In  my  experience  this 
has  certainly  not  been  the  rule,  though  in  some  instances  it  has  seemed 
to  be  true.  If  the  cough  is  aggravated  or  the  patient  finds  the  exposure 
to  the  open  air  decidedly  distasteful,  it  is  proper  to  give  them  the  shelter 
of  the  room. 

In  the  very  old  or  very  feeble  great  care  should  be  exercised  to  see 
that  the  technique  is  perfect,  for  chilling  of  the  surface  of  the  skin  may 
grievously  imperil  these  patients.  In  this  measure,  as  in  any  other, 


PNEUMONIA  157 

common  sense  must  be  exercised  and  the  reaction  of  the  patient  is  the 
true  criterion  of  success,  or  failure. 

Hydrotherapy.  Another  therapeutic  measure  having  similar 
results,  effected  in  a  similar  manner,  is  hydrotherapy. 

I  quote  from  my  article  contributed  to  the  New  York  Medical  Journal 
for  Jan.  8,  1910: 

"Water  is  used  locally  (1)  to  serve  the  purposes  of  cleanliness  and 
hygiene  in  the  daily  bath;  (2)  to  afford  momentary  comfort,  cooling  the 
skin  and  refreshing  the  patient,  and  (3)  to  influence  the  disease." 

This  last  is  the  most  important  and  can  be  done  by  means  of  the  sheet 
bath,  tub-baths,  cold  sponging,  compresses  and  other  devices. 

In  this  country  we  owe  largely  to  Baruch's  persistency  what  benefit 
is  accruing  to  us  from  this  mode  of  treatment.  He  maintains,  and 
logically,  that  good  results  can  come  only  from  observance  of  the  tech- 
nique. 

His  own  preference  in  pneumonia  is  the  chest  compress.  I  cannot 
do  better  than  quote  his  precise  directions  and  urge  that  they  be  followed 
exactly  rather  than  attempt  to  duplicate  measures  only  vaguely  re- 
ferred to. 

"The  chest  compress  is  prepared  by  cutting  three  folds  of  old 
linen  of  a  sufficient  size  to  fit  the  entire  chest  from  the  clavicle  down  to 
the  umbilicus,  with  arm  holes  in  the  region  of  the  axillae,  made  by  exact 
measure  from  one  axilla  to  the  other,  sufficiently  deep  to  allow  the  upper 
edge  of  the  compress  to  reach  above  the  clavicles  and  admit  of  the 
junction  of  the  flap  thus  formed  on  each  side  to  cover  the  shoulders. 
Two  such  jackets  and  two  pieces  of  closely  woven,  thin  flannel  of  the 
same  shape,  but  an  inch  wider  and  longer  should  be  provided  and  fitted 
to  the  patient.  One  of  the  linen  compresses  is  rolled  up  and  soaked  in  a 
basin  of  water  at  60°  F.  and  wrung  out  so  that  it  remains  quite  damp 
without  dripping.  The  flannel  is  now  stretched  out  upon  an  even  surface 
and  the  wet  compress  put  upon  it,  so  that  there  remains  an  edge  of  flannel 
about  an  inch  wide  all  around.  Both  are  rolled  together  halfway,  while 
the  patient  is  gently  turned  upon  his  left  side  with  the  precaution  of  not 
allowing  any  exertion  on  his  part,  the  compress  is  so  placed  upon  the  bed 
that  the  rolled  part  lies  in  close  proximity  to  the  left  side  of  the  patient 
and  the  lower  edge  of  the  left  slit  is  under  the  left  axilla.  Now  the  patient 
is  quietly  turned  upon  his  back,  so  as  to  release  the  rolled  up  portion. 
The  latter  is  now  unrolled  and  both  edges  of  the  compress  are  brought 
upward  upon  the  front  of  the  chest  and  are  thus  made  to  envelope  the 
latter  snugly.  The  flannel  cover  which  has  been  allowed  to  lie  upon 
the  bed  during  the  application  of  the  wet  compress  is  now  brought  for- 
ward, so  as  to  cover  the  latter.  It  is  secured  by  two  safety-pins  in  front 


158  TREATMENT  OF  ACUTE  INFECTIOUS  DISEASES 

and  one  pin  upon  each  shoulder."  He  goes  on  to  say  that  it  should  fit 
snugly,  but  not  so  tightly  as  to  embarrass  breathing.  As  long  as  the 
rectal  temperature  is  above  99.5°  F.  it  is  to  be  renewed  about  every  hour. 
A  fresh  compress  should  always  be  ready  foj  an  immediate  application, 
so  that  the  chest  shall  not  be  exposed.  Before  taking  it  off,  insert  the 
finger  beneath  the  compress  to  see  if  it  is  thoroughly  warm  as  it  is  not  to 
be  renewed  if  it  is  still  cool.  Dr.  Baruch  further  adds:  "In  the  average 
case  a  temperature  of  60°  F.  will  be  appropriate.  Should  the  patient 
evince  stupor  or  muttering  delirium,  a  lower  temperature  should  be 
adopted  and  the  chest  should  receive  one  or  more  dashes  of  colder  water 
before  the  renewal  of  each  compress.  The  same  procedure  is  indicated  in 
broncho-pneumonia,  when  the  bronchi  are  blocked  by  secretions  or 
cyanosis  exists.  A  higher  temperature  than  60°  F.  may  be  used  if  there 
is  much  jactitation,  insomnia  or  excitability.  In  the  latter  event  great 
benefit  will  accrue  from  allowing  the  compress  to  remain  two  hours 
and  moistening  it  more  thoroughly  before  application,  thus  converting 
the  compress  into  a  soothing  fomentation  that  is  not  relaxing  like  a 
poultice."  If  the  patient  remains  cold  and  blue  and  the  compress  does 
not  become  warm,  then  the  flannel  alone  is  applied  until  the  skin  be- 
comes warm  and  a  mustard  foot-bath  may  be  utilized. 

The  rationale  of  the  procedure  is  put  as  follows: 

It  is  asserted  that  "when  the  cold  compress  is  applied,  there  is  a 
rapid  contraction  of  the  cutaneous  vessels,  which  raises  the  tension 
at  once,  which  eventuates  in  a  tonic  dilation  of  these  vessels,  which 
is  evidenced  by  a  ruddy  hue  of  the  skin.  This  dilation  differs  decidedly 
from  that  relaxed  condition  of  the  cutaneous  vessels  produced  by  warm 
poultices.  The  latter  relax  the  vaso-constrictors,  producing  a  paretic 
condition  of  the  vessels  or  a  stasis,  while  cold  applications  stimulate  the 
vaso-dilators,  giving  rise  to  an  active  dilatation,  with  maintenance  of 
tone  of  the  vessels,  an  active  hyperaemia,  by  reason  of  which  the  blood  is 
propelled  more  vigorously  through  them."  The  heart  is  relieved  by  the 
increased  tone  in  the  vessels.  It  has  been  shown  that  the  pulmonary 
vessels  are  supplied  by  nerves  rising  from  the  second  to  the  seventh 
dorsals;  the  somatic  supply  is  distributed  to  the  skin  of  the  chest  and 
abdomen  as  far  as  the  umbilicus.  Through  the  effect  on  this  area  of  the 
cold  compress  undoubtedly  influences  are  exerted  reflexly  on  the  pul- 
monary vessels.  The  improvement  is  seen  in  a  diminution  of  the  nervous 
manifestations,  deepening  of  respiration,  with  relief  of  dyspnoea;  better 
tension  in  the  arteries,  better  sleep,  improved  appetite  and  freer  func- 
tioning of  skin  and  kidneys. 

The  sheet  bath,  which  is  applied  to  the  body  at  large  rather  than  to 
merely  the  chest  as  in  the  chest  compress,  is  another  excellent  measure, 


PNEUMONIA  159 

not  only  to  control  excessive  temperature,  but  also  to  afford  stimulation 
to  circulation,  respiration  and  depressed  or  toxic  cerebral  centres.  No 
better  description  can  be  given  of  the  technique  than  in  Dr.  Baruch's  own 
words  taken  from  his  admirable  book  Hydrotherapy  as  follows: 
"  Technique : — One  side  of  the  patient's  bed  or  adjoining  cot  is  protected 
by  a  rubber  sheet.  A  blanket  is  spread  upon  the  latter.  Several  linen 
sheets,  ...  a  basin,  a  bucket  of  water  of  the  required  temperature,  a 
cup  and  a  sponge  are  placed  upon  a  chair. .  The  sheet,  being  partly  wrung 
out  of  water  of  from  50°  to  80°  F.,  according  to  the  effect  aimed  at,  is 
spread  upon  the  bed  as  rapidly  as  possible  to  prevent  a  change  of  its 
temperature.  The  head  and  face  of  the  patient  being  bathed  with  ice 
water  and  a  wet  turban  wrapped  around  his  head,  he  is  laid  upon  the 
wet  sheet  and  is  wrapped  with  it  in  the  following  manner:  the  patient 
is  directed  to  hold  both  arms  above  his  head.  The  upper  left  border  of 
the  sheet  is  now  brought  close  under  the  left  axilla  and  laid  across  the 
front  of  his  chest,  reaching  beyond  the  axillary  line  of  the  right  side,  the 
lower  portion  is  placed  over  the  pelvis  and  the  edge  tucked  in  between 
the  lower  extremities.  The  arms  are  brought  down  and  placed  alongside 
the  body,  from  which  they  are  separated  by  the  intervening  sheet.  Now 
the  right  portion  of  the  sheet  is  carried  across  the  body  above  and  below, 
enveloping  the  arms  and  shoulders  as  well  as  the  lower  extremities.  The 
right  upper  border  of  the  sheet  is  firmly  drawn  over  the  left  shoulder  and 
securely  tucked  under  the  latter;  the  lower  end  is  tucked  underneath  the 
heels.  In  this  manner  the  patient  is  snugly  enveloped  in  the  wet  sheet 
and  no  uncovered  parts  of  the  body  lie  in  apposition.  The  arms  may,  in 
feeble  patients,  be  left  out  altogether  and  simply  bathed  during  the 
process.  This  will  also  facilitate  the  application  of  the  sheet.  The 
first  impression  will  be  a  shock  to  the  peripheral  nerves,  caused  by  the 
sudden  contact  of  the  cold,  wet  sheet.  A  deep  gasping  inspiration,  and 
a  little  shivering  follow.  These  are  readily  overcome  by  the  patient's 
own  high  temperature,  and  their  removal  is  now  aided  by  the  manipula- 
tions of  the  bath  nurse,  who,  with  outstretched  hands,  gently,  but  firmly 
and  gradually  sweeps  over  the  wet  sheet,  passing  over  the  entire  body 
successively.  Small  portions  of  the  body  should  then  be  rubbed  in  this 
manner  until  they  warm  up.  So  soon  as  any  part  of  the  body  becomes 
thoroughly  warmed,  water  from  50°  to  60°  F.,  according  to  the  condition 
of  the  patient,  is  poured  from  a  cup  or  squeezed  from  a  sponge  over  it  and 
rubbing  is  resumed.  When  the  treated  part  ceases  to  warm  under  the 
friction,  the  attendant  proceeds  to  another  part.  These  gentle,  but  firm 
passes  or  friction  over  successive  parts  of  the  body  are  alternated  with 
the  pouring  on  of  quantities  of  cold  water,  until  the  entire  body  feels 
cooled  and  the  patient  shivers.  Rigor  and  chattering  of  teeth  must 


160  TREATMENT  OF  ACUTE  INFECTIOUS  DISEASES 

always  be  avoided,  because  they  are  an  evidence  of  muscular  contraction, 
and  of  a  too  decided  temperature  difference  between  the  central  and 
peripheral  portions  of  the  body,  which  causes  the  former  to  rise  and  thus 
counterbalance  the  effect.  Friction  prevents  this  objectionable  feature 
of  all  cold  baths  and  enables  us  by  the  renewed  application  of  cold  water 
upon  the  warm  part  of  the  sheet  to  maintain  the  cooling  effect.  After 
its  termination,  the  patient  is  rapidly  dried,  the  sheets  and  blankets  and 
rubber  sheets  are  withdrawn  by  rolling  him  upon  his  side  and  without 
disturbance.  It  is  not  necessary  to  apply  friction  in  drying,  except  to 
the  extremities.  We  have  in  the  sheet  bath  an  admirable  antifebrile 
procedure,  the  effect  of  which  may  be  greatly  enhanced  by  allowing  the 
patient  to  remain  in  it,  leaving  him,  without  drying  at  all,  packed  snugly 
in  the  blanket  and  wet  sheet  for  half  an  hour.  Its  mildness  as  compared 
with  the  full  cold  baths,  renders  it  more  acceptable  to  the  patient  and  his 
friends  and  it  may  thus  be  utilized  as  a  valuable  initiatory  measure, 
intermediate  between  the  ablution  and  the  half-bath." 

The  sheet  bath  may  be  repeated  at  four-hour  intervals  or  at  greater 
or  lesser  intervals,  according  to  temperature.  The  rationale  of  the 
treatment  is  the  same  as  that  described  under  the  chest  compress  above. 

The  cold  baths  may  be  utilized  for  the  same  purpose,  but  the  movable 
tub  is  difficult  to  secure  in  private  practice  while  it  necessitates  more 
handling  of  the  patient  which  is  not  always  desirable  in  the  highly 
toxic  states. 

Personally,  I  am  not  willing  to  forego  the  benefit  of  the  open-air 
treatment  for  the  hydrotherapeutic;  for  one  can  see  that  hourly  and 
half-hourly  changes  of  compresses  or  frequently  administered  sheet  baths 
are  scarcely  compatible  with  what  I  have  described  as  the  open-air 
treatment.  As  I  have  said  before  I  believe  that  the  success  of  the  open- 
air  treatment  is  due  in  no  small  measure  to  the  cold;  so,  in  the  warmer 
seasons  the  cold-water  treatment  could  be  better  applied.  Again,  where 
it  was  evident  that  the  open-air  treatment  was  not  meeting  our  expecta- 
tions, nervous  symptoms,  excitability,  and  so  forth,  increasing,  or  stupor 
deepening,  we  can  have  recourse  to  hydrotherapy. 

Moreover,  the  applications  of  compresses  or  the  giving  of  sheet  baths 
day  and  night,  when  a  patient  needs  sleep,  does  not  accord  with  my 
definition  of  rest.  I  believe  that  real  results  can  be  obtained  from  the 
less  nagging  procedure  of  the  open-air  treatment. 

Symptomatic  Treatment.  As  has  been  said,  symptoms  may 
be  looked  upon  as  purposeful  expressions  of  the  body's  efforts  to  ac- 
complish something  useful  for  itself;  but  that  it  is  possible  for  Nature  in 
this  effort  to  overshoot  the  mark  and  for  the  symptoms  to  become, 
per  se,  a  source  of  danger. 


PNEUMONIA  161 

Fever.  There  is  abundant  reason  to  believe  that  the  febrile  reac- 
tion favors  the  efforts  of  the  body  to  kill  the  invading  organism  and  to 
protect  itself  against  its  ravages.  In  a  frank  pneumonia,  a  certain 
amount  of  temperature  may  be  looked  upon  as  a  favorable  reaction; 
certain  it  is  that  a  low  temperature,  in  the  presence  of  a  severe  intoxica- 
tion, offers  an  ominous  outlook.  A  patient,  then,  with  lobar  pneumonia, 
running  a  temperature  from  104°  F.  to  105°  F.  requires  no  interference 
to  affect  the  temperature  itself. 

If,  however,  the  temperature  rises  much  above  these  points  or  the 
disease  is  prolonged  and  the  temperature  sustained,  pyrexia,  per  se, 
becomes  a  source  of  danger  and  must  be  combated.  There  is  but  one 
antipyretic  that  is  warrantable  under  these  conditions  and  that  is 
cold  water.  One  may  have  recourse  to  the  cold  bath,  given  after 
the  manner  of  the  Brand  bath  or  its  modification,  the  Zeimssen's  bath,  or 
the  slush,  given  in  bed,  just  as  described  under  Typhoid  Fever.  (See 
Chap.  XIV.)  It  must  be  remembered,  however,  that  it  is  our  wish  only 
to  bring  the  temperature  down  below  the  danger  point  and  that  if  the 
patient  is  too  long  exposed  to  the  cold,  his  temperature  may  become 
subnormal  and  he  may  go  into  collapse.  It  is  a  good  rule,  then,  to 
remove  the  patient  from  the  tub,  when  his  temperature  falls  to  102°  F. 
to  102.5°  F.  When  the  cold  bath  or  slush  cannot  be  used,  the  cold  pack  or 
sheet  bath  may  be  tried;  a  sheet  wrung  out  of  cold  water,  wrapped  about 
the  patient  and  then  the  surface  of  the  sheet  rubbed  down  with  pieces  of 
ice,  as  detailed  above. 

Less  effectual  are  simple  cold  sponges. 

Rectal  injections  of  cold  water  have  some  value  in  lowering 
temperature. 

The  only  justification  for  the  use  of  drugs  for  reducing  temperature  is 
an  environment  that  does  not  permit  of  the  use  of  cold  water. 

The  drugs  used  are  those  commonly  classified  as  antipyretics;  anti- 
pyrin,  acetanilid  and  phenacetin  (acetphenetidin),  and  these  must  be 
used  cautiously  because  of  their  depressing  effect  upon  the  circulation. 

Cough.  The  cough  of  pneumonia  may  be  due  to  bronchitis  or  to  an 
accompanying  pleurisy.  In  lobar  pneumonia  there  is  an  abundant 
pleural  exudate  as  a  rule  and  cough  due  to  it  is  common.  In  broncho- 
pneumonia  there  is  usually  a  considerable  element  of  bronchitis  and  this 
is,  of  course,  a  common  source  of  the  cough.  (See  Bronchitis,  Chap.  VII.) 

Treatment  of  Pleurisy.  For  the  cough  of  pleurisy  the  treat- 
ment is  aimed  at  a  relief  of  this  condition. 

Rest  to  the  pleural  surfaces  is  of  prime  importance  and  this  can  be 
attained  by  strapping  the  chest;  thus  lessening  the  movement  of 
one  pleural  surface  upon  the  other.  Next,  we  have  recourse  to  local 
applications,  which  are  supposed  to  act  reflexly  upon  the  nervous  and 


162  TREATMENT  OF  ACUTE  INFECTIOUS  DISEASES 

vascular  supply  of  the  pleura  to  lessen  pain  and  possibly  modify  the 
processes  of  inflammation.  They  are  counterirritation  with  the  ac- 
tual cautery,  lightly  flicked  along  the  course  of  the  intercostal  nerves; 
the  application  of  mustard  paste  or  piaster*;  in  children  in  the  pro- 
portion of  one  part  of  mustard  to  four  or  five  of  flour;  in  adults,  one  part 
in  three,  to  equal  parts,  left  on  for  ten  or  fifteen  minutes  or  until  the 
surface  is  reddened  and  reapplied  at  two,  three,  or  four  hour  intervals. 

Heat  in  the  shape  of  poultices,  fomentations  and  the  hot  water 
bottle  or  cold  by  application  of  the  ice  bag. 

Strapping  the  Chest.  If  the  patient  is  not  too  ill  he  should 
be  in  the  sitting  position  in  bed.  If  this  position  is  not  feasible,  he  should 
lie  on  the  non-affected  side. 

The  plaster  to  be  used  is  the  "so-called"  zinc  oxide  plaster,  because 
the  least  irritating.  A  strip  about  five  inches  wide  that  will  reach  from 
the  axillary  fold  to  the  edge  of  the  rib  is  cut  long  enough  to  enclose  the 
affected  side,  overlapping  in  front  and  behind  for  two  or  three  inches. 
One  end  of  this  strip  is  applied  two  or  three  inches  beyond  the  spine  on 
the  unaffected  side,  the  patient  is  instructed  to  breathe  out  and  hold  the 
breath,  while  the  operator  holding  the  strip  smooth  to  avoid  any  wrinkles 
applies  it  snugly  to  the  affected  side,  carrying  it  two  or  three  inches 
beyond  the  mid-line  in  front.  It  is  sometimes  better  to  use  strips  two  or 
three  inches  wide,  overlapping  them  like  clapboards  on  a  house;  this 
particularly  where  the  conformity  of  the  chest,  much  adipose  tissue,  or 
the  large  breasts  of  a  female,  make  the  application  without  wrinkles 
difficult  or  impossible. 

If  there  is  much  hair  upon  the  chest,  this  should  be  shaven  before  the 
strip  is  applied,  to  facilitate  its  removal  when  necessary. 

The  Application  of  Mustard.  One  may  use  the  mustard  leaf 
(charta  sinapis),  although  I  think  the  paste  is  preferable. 

The  mustard  leaf  is  dipped  into  luke-warm  water  to  initiate  the 
elaboration  of  the  oil  of  mustard,  a  single  layer  of  gauze  applied  to  its 
surface  and  two  or  three  to  its  back,  and  applied,  the  mustard  side 
towards  the  chest. 

The  paste  is  made  by  mixing  one  tablespoonful  of  mustard  to  two, 
three,  or  four  of  flour  with  cold  water  to  the  consistency  of  a  paste  and 
spreading  it  nicely  on  gauze  or  cheesecloth.  This  is  covered  with  gauze 
and  applied  to  the  chest.  Care  must  be  taken  to  use  cold  or  luke-warm 
water,  as  heat  kills  the  ferment  concerned  in  the  elaboration  of  the  oil. 
The  paste  is  kept  on  ten  or  fifteen  minutes,  then  removed  and  to  the 
skin  is  applied  a  layer  of  sweet  oil  or  vaseline. 

If  the  skin  is  very  sensitive,  the  white  of  an  egg  or  a  little  oil  or  vaseline 
added  to  the  paste  will  make  it  less  irritating. 


PNEUMONIA  163 

Application  of  the  Poultice.  Take  three  cups  of  water  and  two 
and  one-half  cups  of  flax-seed  meal.  Bring  the  water  to  a  boil  and  add 
the  meal  slowly,  stirring  it  all  the  time  with  a  spoon.  When  the  mixture 
is  so  thick  that,  poured  from  a  spoon  it  falls  drop  by  drop,  ifc  is  beaten 
quickly  to  make  it  light  and  then  is  spread  evenly  over  a  muslin  or  gauze, 
being  made  about  one-quarter  inch  in  thickness.  A  margin  of  gauze  of 
some  two  inches  should  be  left  all  around  to  turn  back  over  the  edge  of 
the  poultice.  The  poultice  is  then  covered  with  gauze,  this  being  cut  to 
have  a  margin  of  three  inches  to  fold  in  and  turn  under  the  muslin,  be- 
tween it  and  the  protector.  The  protector  is  usually  a  piece  of  oil-silk  or 
old  flannel,  which  serves  to  keep  in  the  heat.  A  binder  is  placed  under 
the  patient  and  a  poultice  is  brought  to  him  on  a  hot  plate  to  keep  it 
warm,  the  heat  is  tested  against  the  face  of  the  nurse,  to  determine  that  it 
is  not  so  hot  as  to  burn  the  patient;  it  is  then  applied  slowly,  so  that 
the  heat  can  be  better  borne  and  the  binder  brought  up  around  the 
poultice. 

The  poultice  should  not  be  kept  on  longer  than  an  hour,  because  it 
grows  cold  by  that  time,  unless  some  device  like  a  hot  water  bottle  par- 
tially filled  to  avoid  weight  or  a  Japanese  hand-stove  is  applied  to 
it  to  keep  the  heat  up.  When  the  poultice  is  removed,  the  site  of 
its  application  is  smeared  with  oil  or  vaseline  and  covered  with  a  dry 
flannel. 

Application  of  a  Fomentation.  Cut  two  or  three  thicknesses 
of  flannel,  sufficiently  large  to  cover  the  chest.  This  flannel  is  placed  in  a 
crash  towel,  boiling  water  poured  upon  it,  the  ends  of  the  towel  twisted 
in  opposite  directions  to  squeeze  the  water  from  the  flannel;  the  skin  is 
smeared  with  vaseline  or  sweet  oil  and  the  flannels  applied  with  dry 
flannel  outside,  all  of  which  are  kept  in  place  by  a  binder.  These  are 
renewed  as  fast  as  they  become  cool.  Care  must  be  taken  that  not 
enough  hot  water  is  left  in  them  to  drip  down  upon  the  skin  and 
burn. 

Application  of  the  Ice-Bag.  Perhaps  the  best  bag  to  use  is  the 
circular  ice  bag  with  a  circular  metallic  cap;  the  nine-inch  English 
ice  bag  is  the  best. form.  The  bottom  of  the  bag  is  covered  with  ice 
cracked  to  the  size  of  the  end  of  one's  thumb;  over  this  is  poured  just 
enough  water  to  cover  the  ice,  then  the  bag  is  compressed  so  that  the 
water  comes  to  the  surface  of  the  opening,  thus  excluding  all  the  air. 
The  cap  is  then  screwed  on.  This  exclusion  of  the  air  leaves  the  bag 
supple  and  makes  it  easily  applicable  to  any  curved  surface.  The  bag 
is  then  covered  with  a  layer  of  cheesecloth  or  linen,  to  intervene  be- 
tween the  bag  and  the  skin  and  the  bag  is  held  on  by  a  binder  or  by  a 
towel.  This  should  be  taken  off  from  time  to  time,  at  intervals  of  at  least 


164          TREATMENT  OF  ACUTE  INFECTIOUS  DISEASES 

two  or  three  hours,  as  continuous  cold  can  produce  damage  to  the  skin 
and  the  underlying  tissues.  When  the  bag  is  taken  off,  oil  may  be 
applied.  (For  details  of  these  and  similar  procedures,  one  should  have 
recourse  t6  such  an  excellent  little  book  as"  that  of  Practical  Nursing  of 
Maxwell  and  Pope.) 

When  these  local  measures  are  not  efficacious  and  the  pain  and  the 
cough  is  severe,  it  is  necessary  to  have  recourse  to  some  anodyne.  Per- 
haps one  of  the  mildest  and  most  effectual  is  codeine,  which  may  be 
given  in  doses  of  gr.  1/8  to  gr.  1/4  (0.008-0.015  Gm.)  at  two-hour 
intervals. 

If  these  are  not  effectual  when  given  by  the  mouth  they  may  be  given 
hypodermically. 

In  the  most  severe  cases,  however,  it  is  necessary  to  use  morphine. 
It  is  well  to  begin  with  as  small  a  dose  as  will  be  effectual,  gr.  1/16  to 
gr.  1/12  (0.004  to  0.008  Gm.).  This  can  be  repeated  at  four-hour  inter- 
vals; and  if  necessary  the  dose  increased  to  gr.  1/8,  gr.  1/6  orgr.  1/4 
(0.008,  0.010,  0.015  Gm.). 

The  Treatment  of  Bronchitis.  While  the  cough  due  to  pleurisy 
is  exhausting  and  has  no  purpose  in  view,  the  cough  due  to  bronchitis  is 
of  very  real  use  to  the  patient,  in  that  it  empties  the  bronchi  of  secretions. 
A  certain  amount  of  coughing,  then,  that  effects  this  end  is  desirable;  but 
when  the  irritation  continues  and  induces  exhaustion  an  effort  must  be 
made  to  remove  it.  This  cough  is  not  infrequently  relieved  by  the 
application  of  a  mustard  paste  just  as  described  above.  Another  meas- 
ure of  great  value,  where  the  bronchitis  is  intense  and  the  congestion  of 
the  bronchi  very  marked,  in  those  cases  where  the  narrowing  of  the 
bronchi  simulate  a  spasmodic  asthma  or  not  infrequently  leads  one  to 
feel  the  possibility  of  edema,  is  a  vigorous  cupping,  all  over  the  chest. 
Wet  cupping  was  once  much  in  vogue  in  these  conditions,  but 
to-day  is  rarely  made  use  of.  The  dry  cupping  is  the  measure  of  which  I 
speak. 

Technique  of  Cupping.  There  are  special  cups  made  for  this 
purpose,  but  it  is  scarcely  necessary  to  obtain  these,  for  any  small  glass, 
such  as  a  medicine  glass,  wine  glass,  egg-glass  will  answer.  It  is  de- 
sirable that  they  should  be  of  rather  thin  glass,  lest  their  own  weight 
should  be  so  great  as  to  displace  them.  The  site  of  the  cup  should  be 
cleaned  before  the  application.  One  produces  a  partial  vacuum  in  the 
cup  and  one  of  the  simplest  means  is  to  drop  a  shred  of  absorbent  cotton 
into  the  cup,  light  it  and,  while  it  is  burning,  invert  the  cup  and  clap  it 
upon  the  part  to  which  it  is  to  be  applied. 

Another  method  is  to  smear  the  inside  of  the  cup  with  a  thin  film  of 
alcohol.  This  is  best  done  with  absorbent  cotton  on  an  applicator, 


PNEUMONIA  165 

dipped  into  alcohol  and  swabbed  on  the  inside  of  the  glass,  then  light  it 
and  apply  while  it  is  aflame.  One  should  be  very  careful,  however,  to 
have  no  excess  of  alcohol,  as  a  drop  of  it  running  on  to  the  skin  may 
cause  quite  a  severe  burn. 

Another  excellent  modification  is  to  light  over  an  alcohol  flame  the 
cotton  swab  saturated  with  alcohol  and  quickly  rub  this  burning  swab 
around  the  interior  surface  of  the  glass,  avoiding  the  rim  of  the  cup,  lest 
it  become  hot.  This  cup  is  then  rapidly  applied  while  the  vacuum  still 
obtains. 

Following  the  application  of  the  cup,  the  skin  is  drawn  up  into  the  cup 
and  becomes  deeply  congested;  the  negative  pressure  may  be  so  great  as 
to  form  an  ooze  of  serum  on  the  surface,  standing  in  little  drops.  This, 
however,  is  not  desirable,  although  it  does  no  harm. 

The  cups  remain  until  the  skin  looks  well  congested.  In  order  to  take 
off  the  cup  one  depresses  the  skin  at  the  edge  of  the  cup  to  let  in  the  air. 
If  the  cup  is  to  be  reapplied,  it  must  be  thoroughly  wiped  free  of  the 
moisture  produced  by  combustion  of  the  alcohol. 

The  improvement  following  this  measure  is  sometimes  very  striking. 

Wet-Cups.  If  the  patient  is  plethoric  and  cyanotic,  the  wet-cups 
may  be  used  with  benefit.  A  special  apparatus  is  supplied  for  this 
purpose  which  consists  of  an  instrument  with  a  small  number  of  lancet 
blades  which,  when  the  instrument  is.  applied  to  the  skin  and  a  spring 
touched,  spring  forth  and  incise  the  skin. 

Over  this  bleeding  surface  a  dry  cup  is  applied  in  the  manner  de- 
tailed above,  sucking  the  blood  out  of  the  wound,  acting  as  an  arti- 
ficial leech.  It  is  rarely  necessary  to  repeat  this  procedure. 

Inhalations.  Inhalations  of  steam  or  medicated  steam  are  often 
found  grateful  and  relieve  the  cough  materially. 

For  this  purpose  one  may  use  the  common  croup-kettle  or  some 
simpler  substitute  on  the  market,  or  manufacture  a  device  by  using 
a  kettle  or  pitcher  with  a  paper  cone  to  conduct  the  steam.  In  children 
the  steam  may  be  led  into  a  tent  which  is  made  by  throwing  a  sheet  over 
the  four  posts  or  over  laths  attached  to  the  four  bed-posts  to  give  it 
elevation  or  by  throwing  a  sheet  over  an  open  umbrella  under  which  the 
child  lies. 

Medication  used  in  the  steam  may  be  either  the  compound  tinc- 
ture of  benzoin,  oil  of  pine  or  oil  of  eucalyptus.  One  places  one 
or  two  drams  (4-8  c.c.)  of  such  upon  the  surface  of  the  water.  In  spe- 
cially devised  croup-kettles,  a  sponge  is  placed  in  the  nozzle,  to  which 
when  moistened  the  medication  is  applied;  steam  circulating  through 
this  takes  up  the  medicament  and  is  inhaled  by  the  patient. 

Another  excellent  prescription  is: 


166  TREATMENT  OF  ACUTE  INFECTIOUS  DISEASES 


Mentholis. 

Camphorae  ....................................  aa  3i          (4) 

Tinct.  Benzoin!  Co.q.  s.  ad  .............  ^  ...........  5"       (60) 

S.  Use  a  teaspoonful  to  a  pitcher  of  hot  water  as  an  inhalation. 

One  of  the  most  effectual  inhalations  with  which  I  am  acquainted  is 
one  used  by  Dr.  Francis  Delafield  and  consists  of  the  following  pre- 
scription : 

9 

Alcohol  . 

Chloroform  . 

Creosote  .......................................  equal  parts. 

S.  Put  10  drops  of  this  upon  the  moistened  sponge  of  a  Robinson's  in- 
haler or  some  kindred  device. 

The  inhaler  is  a  perforated  zinc  sheet,  bent  to  fit  over  the  mouth 
and  nose  and  this  may  be  worn  by  the  patient  as  long  as  it  gives  relief. 

If  these  local  procedures  and  inhalations  do  not  afford  relief  one  has  to 
have  recourse  to  sedatives. 

Drugs.  Codeine  and  morphine  may  be  used  in  the  same  doses 
as  for  the  cough  of  pleurisy.  Sometimes  relief  is  afforded  by  heroine 
when  neither  morphine  nor  its  derivative  codeine  is  effectual.  It  should 
only  be  used  when  the  others  fail  and  it  should  be  remembered  that  it 
is  a  very  decided  respiratory  depressant.  The  dose  usually  is  gr.  1/20 
to  1/12,  (0.003  to  0.005  Gm.)  of  the  hydrochloride.  Terpin  hydrate  is 
sometimes  combined  with  heroine  with  happy  results.  It  is  best  admin- 
istered as  the  Elixir  Terpini  Hydratis  cum  Heroina  of  the  national 
formulary,  each  dram  (4  c.c.)  of  which  contains  1  grain  (0.06  Gm.)  of 
terpin  hydrate  and  grains  1/24  (0.004  Gm.)  of  heroine,  the  dose  being 
1  to  2  drams  (4  to  8  c.c.)  in  water  at  three-hour  intervals  to  meet  the  need. 

Personally  I  have  very  little  faith  in  the  expectorants  and  in  pneu- 
monia never  order  them. 

Those,  however,  who  do  believe  in  expectorants,  will  find  in 
ammonium  chloride  or  carbonate  the  favorites  for  this  purpose  and 
these  may  be  given  in  3  to  5  grain  (0.20-0.30  Gm.)  doses  every  two 
or  three  hours.  It  is  often  well  combined  with  the  syrup  of  Tolu,  e.  g.  : 

S 

Ammonii  Chloridi  .............................  gr.  xlv         (3) 

Syrupi  Tolutani  ..............................  Siv  (8) 

Aquae  q.  s.  ad  .................................  §ii  (60) 

M. 

S.  Teaspoonful  in  water  every  three  hours. 

Pain.    Pain  in  pneumonia  is  a  manifestation  of  pleurisy.    (For  treat- 


PNEUMONIA  167 

menfc  of  pleurisy  see  Chap.  VIII  and  Summary.)  It  is  apt  to  occur 
early.  Sometimes  it  is  trivial  and  sometimes  may  not  occur  at  all. 
Again  the  pain  is  most  intense  and  lasts  for  several  days. 

An  inflammation  of  the  parietal  pleura  gives  rise  to  pain  through  the 
intercostal  nerves  over  the  site  supplied.  There  is  some  pain  on  deep 
pressure  much  more  marked  in  a  purulent  inflammation.  The  hyperas- 
thesia  is  moderate. 

It  must  not  be  forgotten  that  a  pleurisy  occurring  on  the  diaphrag- 
matic surface  by  reflex  through  the  lower  dorsals,  especially  the  last 
dorsal  by  its  lateral  cutaneous  branch  gives  rise  to  pain  in  the  epigas- 
trium and  lower  parts  of  the  abdomen;  simulating  lesions  here,  such  as 
gastric  ulcer,  gall  bladder  disease  and  appendicitis.  The  hyperasthesia, 
with  increased  pain  on  light  pressure,  is  decidedly  less  than  when  the 
abdominal  parietal  peritoneum  is  involved.  However,  the  diagnosis 
of  appendicitis  is  commonly  made  and  before  the  signs  of  consolidation 
are  obvious  often  offers  difficulties  in  differentiation. 

Pain,  too,  through  the  dorsi  lumbar  nerve,  felt  in  the  lumbar  region, 
may  suggest  renal  lesions.  Furthermore,  pain  and  tenderness  in  the 
supraclavicular  region  may  be  attributed  to  involvement  of  the  diaph- 
ragmatic surface,  the  pain  being  a  reflex  derived  through  the  phrenic 
supply. 

This  pain  in  the  supraclavicular  region,  trapezius  crest,  occurring  at 
the  same  time  and  on  the  same  side  as  the  abdominal  or  lumbar  pain 
suggests  the  right  diagnosis.  The  involvement  of  the  precordium  may 
also  give  rise  to  pain  which  will  be  discussed  when  pericarditis  as  a 
complication  is  considered. 

Local  Measures.  These  are  identical  with  those  detailed  to  re- 
lieve the  cough  of  pleurisy;  namely,  application  of  heat,  the  application 
of  cold,  counter-irritation  and  cupping.  In  the  severe  cases  the  use  of 
codeine  and  morphine  as  detailed  above. 

Toxemia.  The  degree  of  toxemia  depends  in  each  instance  upon 
the  virulence  of  the  toxins  on  the  one  hand  and  the  degree  of  resistance 
on  the  other.  As  we  have  no  means  at  present  of  modifying  the  viru- 
lence, except  so  far  as  the  use  of  antitoxin  in  Type  I  pneumonia  cases  is 
efficacious,  we  must  devote  our  attention  to  increasing  the  powers  of 
resistance.  This  is  effected  by  carrying  out  all  these  measures  that  have 
been  touched  upon ;  giving  the  body  its  maximum  rest,  giving  the  body  a 
sufficiency  of  fuel  in  terms  of  food,  giving  the  tissues  a  maximum  of  oxy- 
gen as  afforded  by  fresh  air  and  keeping  in  good  order  the  eliminating 
organs;  that  is,  attention  to  the  bowels,  attention  to  the  kidneys,  and 
attention  to  the  skin;  and  it  must  not  be  forgotten  that  a  sufficiency  of 
water  intake  subserves  all  these  purposes  to  no  small  degree. 


168  TREATMENT  OF  ACUTE  INFECTIOUS  DISEASES 

The  use  of  drugs  to  enhance  these  functions,  except  the  use  of  cathar- 
tics as  mentioned,  are  indicated  only  when  the  organs  show  a  faltering  in 
their  functions  or  when  it  is  known  that  these  organs  are  impaired  in  the 
individual  when  infected  by  the  pneumococcus. 

The  effect  of  toxins  on  the  nervous  system  is  striking  and  not  the 
least  upon  the  cerebrum ;  and  while  it  is  true-  that  a  considerable  area 
of  lung  tissue  may  be  involved  with  practically  no  delirium  or  stupor, 
as  a  rule  one  or  the  other  obtains  to  some  degree  and  in  a  large  per  cent, 
of  cases  to  a  very  marked  degree. 

Delirium,  restlessness  and  loss  of  sleep,  headache  and  stupor  have 
all  to  be  taken  into  consideration.  When  delirium  obtains  the  patient 
must  be  very  carefully  guarded  as  he  may  leave  the  bed;  throw  himself 
from  a  window  or  otherwise  injure  himself.  It  is  in  the  milder  degrees  of 
delirium,  in  which  the  patient,  sick  as  he  is,  may  show  no  little  craftiness, 
that  the  greatest  danger  exists.  This  emphasizes  the  necessity  for 
watchfulness  when  the  patient  is  submitted  to  the  open-air  treatment. 

The  open-air  treatment,  however,  or  the  hydrotherapeutic  meas- 
ures described,  lessen  the  degree  of  cerebral  disturbances,  while  suffi- 
ciency of  food,  water  and  attention  to  the  bowels  add  still  more  to  the 
amelioration  of  this  condition. 

The  application  of  the  ice  bag  or  ice  coil  to  the  head  has  at  times  a 
sedative  effect.  When  all  the  symptoms  are  marked  one  has  to  keep  in 
mind  the  possible  involvement  of  the  meninges;  a  differential  diagnosis 
between  a  true  meningitis  and  a  meningismus  is  not  easy.  The  latter 
term  is  used  often  to  cover  both  the  irritating  effects  of  the  toxin  on 
the  brain  without  evidence  of  inflammatory  reaction  in  the  cerebro- 
spinal  fluid  and  also  for  a  serous  meningitis.  Many  of  the  signs  of  true 
meningitis  are  commonly  manifested  in  a  meningism  and  one  can  only 
be  certain  of  the  true  state  of  affairs  by  a  spinal  puncture;  and  a 
lumbar  tap  has  great  value  as  a  therapeutic  measure,  even  if  the  condi- 
tion is  that  of  meningismus.  While  I  do  not  advocate  spinal  puncture 
without  sufficiently  urgent  reasons,  I  think  the  procedure  is  distinctly 
indicated  in  the  condition  under  discussion.  The  relief  of  headaches, 
restlessness  and  the  amelioration  of  the  delirium  is  often  very  striking. 

(For  the  procedure  see  Meningitis,  Chap.  XXV.) 

Drugs.  In  the  milder  forms  of  delirium,  codeine  phosphate  is 
sufficient  and  best  administered  hypodermically  in  doses  of  gr.  1/8  to  1/4 
(0.008  to  0.015  Gm.).  In  the  more  severe  forms,  one  must  have  recourse 
to  morphine  sulphate.  It  should  be  used  as  sparingly  and  in  as 
small  doses  as  will  accomplish  the  object.  One  may  begin,  then,  with  a 
dose  of  gr.  1/16  to  gr.  1/12  (0.004  to  0.005  Gm.). 

It  is  possible  that  in  some  individual  cases  the  morphine  may  not 


PNEUMONIA  169 

be  effectual  or  may  aggravate  the  restlessness.  In  such  a  case  one  may 
have  recourse  to  hyoscine  hydrobromide  gr.  1/200  to  gr.  1/100  (0.0003 
to  0.0006  Gm) .  This  drug  is  not  always  reliable. 

Sleeplessness  and  Restlessness.  For  milder  grades  one  may 
use  bromides,  either  dividing  the  dose  throughout  the  day  or  giving 
a  larger  dose  at  night.  In  the  latter  case  one  gives  in  water  gr.  xxx  to 
3i  (2  to  4  Gm.)  of  potassium  bromide  or  a  mixture  of  bromides,  potas- 
sium, sodium  and  ammonium,  each  gr.  x  (0.60  Gm.). 

If  the  bromides  are  not  effectual,  one  should  try  the  milder  hypnotics, 
such  as  trional,  sulphonal,1  chloralamid,  veronal,  or  in  alcoholic  cases 
paraldehyde. 

Trional,  more  soluble,  more  prompt  and  more  active  than  sulphonal, 
is  given  in  doses  of  gr.  x-xv  (0.60-1  Gm.)  in  a  little  wine  or  whisky  or 
suspended  in  a  warm  drink  in  the  early  evening  and  if  not  effectual  the 
dose  may  be  repeated  in  two  hours.  Sometimes  the  same  dose  begun 
earlier  in  the  day  and  distributed  in  2  grain  doses  at  2  hour  intervals  is 
equally  or  more  effectual.  If  the  patient  shows  no  disposition  for  sleep 
when  the  hour  for  sleep  arrives,  he  may  be  given  the  larger  dose  of  10 
(0.60  Gm.)  grains,  but  this  latter  reenforcement  frequently  is  not  nec- 
essary. 

Again  5  grain  (0.33  Gm.)  doses  taken  after  the  last  meal  of  the  day  is 
sufficient  to  initiate  sleep  in  the  milder  cases. 

Chloralamid  is  another  excellent  hypnotic,  given  in  doses  of  gr.  xx  to 
gr.  xxx  (1.30  to  2  Gm.),  in  a  cold  menstruum,  as  heat  breaks  it  up.  This 
is  given  like  trional  and  repeated  in  the  same  way  if  needed. 

Veronal,  or  the  American  made  product  barbital,  is  a  fairly  potent 
hypnotic  which  has  now  come  into  extensive  use.  The  dose  is  5-7  % 
grains,  which  may  be  administered  in  capsule  or  cachet  or  put  on  the 
tongue  and  washed  down  with  water.  This  drug  is  rather  slowly  ex- 
creted and  a  drowsiness  may  continue  well  into  the  next  day.  This 
hypnotic  has  never  been  a  favorite  of  mine  because  of  the  prolonged,  and 
to  the  patient  often  disagreeable  effects,  among  which  are  ataxia,  halluci- 
nations and  tremor.  I  have  always  considered  it  more  toxic  than  the 
other  hypnotics  mentioned. 

Medinal  or  barbital  sodium,  the  latter  name  to  be  preferred,  is  a 
modification  of  veronal  and  far  more  soluble  in  water  (1:5).  This  in- 
creased solubility  permits  of  its  use  by  rectum  or  hypodermatically.  The 
dose  is  the  same  as  that  of  barbital  even  when  given  hypodermatically. 
My  experience  with  this  drug  has  been  limited  and  I  have  never  given 
it  hypodermatically. 

1  The  term  sulphonal  will  be  used  throughout  this  book  in  place  of  the  offi- 
cial name  sulfonmethane. "" 


170  TREATMENT  OF  ACUTE  INFECTIOUS  DISEASES 

Another  mild  hypnotic  which  I  have  come  to  look  upon  with  some 
favor  is  adalin  (brom-di-ethyl-acetyl-carbamide).  The  bromine  radial 
affords  the  sedative  effects  of  bromides  and  the  ethyl  groups  act  as 
hypnotics.  It  is  rather  mild  in  its  action,  rather  freely  soluble  in  alcohol, 
but  not  in  water.  The  dose  is  5-15  grains  (0.33-1  Gm.) ,  given  in  capsules 
or  tablets  or  in  powder  form,  washed  down  with  a  little  water.  It  is  said 
when  taken  in  large  doses  for  a  considerable  time  to  cause  the  usual  skin 
lesions  attributable  to  bromides. 

In  alcoholics  paraldehyde  seems  to  have  an  especially  happy 
effect.  It  may  be  given  in  doses  of  3ij  to  5iv.  It  is  soluble  1  in  8  in  water 
and  in  whisky  or  brandy.  For  ordinary  usage  the  dose  is  somewhat 
smaller,  but  the  bad  taste  and  odor  on  the  breath  makes  it  objectionable. 

Of  chloral,  on  account  of  its  depressing  effect  on  the  medullary  centres, 
I  am  wary,  except  in  the  sthenic  period  of  the  fever. 

One  should  not  allow  the  patient's  strength  to  be  sacrificed  by  loss 
of  sleep  night  after  night,  while  the  results  of  one  and  another  of  the 
milder  hypnotics  is  awaited,  but  should  use  the  most  effectual  of  all 
hypnotics,  morphine. 

Just  as  in  delirium,  the  smallest  dose  to  effect  the  desired  result  is 
given.  Begin  with  a  dose  of  gr.  1/12  to  gr.  1/8  (0.005  to  0.008  Gm.). 

Not  too  much  stress  can  be  laid  on  the  importance  of  securing  sleep. 
The  waste  of  energy  from  restlessness  is  a  matter  of  moment  and  the  evil 
results  of  loss  of  sleep  so  well  known  to  all  of  us  is  greatly  exaggerated 
in  sickness. 

Headache.  The  ice  cap  or  coil  may  be  effectual  or  bromide  in  doses 
of  gr.  xv  to  gr.  xx  (1  to  1.30  Gm.). 

Coal  tars,  such  as  phenacetin,  acetanilid  and  antipyrin  on  account  of 
their  depressant  action  on  the  circulation  should  be  used  only  in  the 
sthenic  periods. 

As  safer  than  coal-tar  preparations,  small  doses,  5-10  grains  (0.33- 
0.66  Gm.)  of  acetyl  salicylic  acid  (aspirin)  in  capsules  may  be  admin- 
istered. 

For  the  very  severe  headaches,  codeine  phosphate  or  sulphate  or 
morphine  sulphate  in  small  doses  are  the  best  drugs  to  use.  Severe 
headaches  should  always  arouse  the  suspicion  of  an  implication  of  the 
meninges.  This  may  be  only  the  so-called  serous  meningitis,  sometimes 
termed  meningismus,  or  a  true  pneumococcus  meningitis.  If  there  are 
other  evidences  of  meningitis,  one  should  tap  the  cord.  In  the  serous 
meningitis  cases  this  procedure  often  affords  prompt  relief  to  headache, 
restlessness,  sleeplessness  and  delirium. 

Circulation.  It  is  the  belief  of  the  present  day  that  in  cir- 
culatory failure  the  vaso-motor  apparatus  is  in  the  vast  majority  of 


PNEUMONIA  171 

instances  the  part  affected  and  that  only  in  a  small  percentage  of  the 
cases  is  the  circulatory  failure  due  to  myocardial  inefficiency.  This, 
however,  does  occur  and,  moreover,  the  heart  may  be  the  seat  of  myo- 
cardial change  before  the  patient  is  the  victim  of  pneumonia.  It  is  not 
easy,  even  by  a  careful  physical  examination  to  determine  in  a  given 
instance,  whether  the  myocardium  or  the  vaso- motor  apparatus  is  at 
fault.  Theoretically,  the  differentiation  should  be  of  great  importance, 
as  on  the  one  hand  one  would  appeal  to  vaso-motor  stimulants,  on  the 
other  to  cardiac  stimulants;  but  practically,  it  makes  very  little  differ- 
ence, for  the  vaso-motor  stimulants  that  we  now  have  recourse  to  are  but 
feeble  assistants  at  the  best,  while  I  am  more  and  more  convinced  that 
whether  the  heart  be  affected  or  not,  in  a  given  case  of  circulatory  failure, 
the  members  of  the  digitalis  series  are  the  most  valuable  drugs  under 
the  circumstances. 

It  is  my  custom  with  the  first  appreciable  evidences  of  circulatory 
disturbance  to  begin  digitalis.  Since  this  sentence  was  written  in  the 
first  edition,  early  digitalization  of  the  heart  in  pneumonia  has  become 
more  or  less  a  routine  in  many  of  our  best  hospitals  and  in  many  of  the 
camps  during  the  late  war. 

It  is  imperative  that  this  drug  should  be  obtained  from  an  absolutely  re- 
liable source  and  that  it  should  be  freshly  prepared.  It  would  be  desir- 
able to  have  all  preparations  of  digitalis  physiologically  assayed,  but  this 
is  rarely  done  at  the  present  time  when  fresh  preparations  are  dispensed, 
but  stock  preparations  of  digitalis  or  the  active  principles  of  digitalis  or 
strophanthin  put  on  the  market  by  many  drug  houses  under  different 
commercial  designations  are  so  standardized  that  stock  preparations  may 
be  used.  It  is  the  only  way  by  which  we  can  estimate  accurately  in  terms 
of  digitalis  our  dosage  in  the  use  of  these  latter  preparations.  It  must  be 
remembered  that  when  digitalis  is  administered  by  the  mouth  it  is  slow 
of  absorption. 

Unless  the  case  is  very  light  and  the  circulation  in  excellent  condition  I 
believe  it  good  practice  to  put  the  heart  under  the  influence  of  digitalis 
when  the  diagnosis  is  established.  Unless  there  is  urgent  need  of  circula- 
tory support  one  may  observe  the  so-called  Eggleston  rule  for  digitaliza- 
tion of  the  heart,  which  calls  for  the  administration  of  about  0.145  c.c.  or 
2  minims  of  the  tincture  of  digitalis  per  pound  of  patient,  the  total 
amount  being  given  in  the  first  24  to  36  hours.  This  dose  reckoned 
for  a  man  of  150  pounds  should  amount  to  nearly  22  c.c.  of  the  tincture 
(or  300  minims)  or  2.2  grams  of  the  drug  (33  grains).  The  initial  dose 
advised  is  a  third  or  a  half  of  the  total  dose,  followed  in  from  4  to  6  hours 
by  a  quarter  or  a  third  of  the  total  dose,  the  remainder  in  a  few  doses  of 
smaller  size  at  intervals  of  from  4  to  6  hours.  Whether  the  larger  or 


172  TREATMENT  OF  ACUTE  INFECTIOUS  DISEASES 

smaller  doses,  shorter  or  longer  intervals  are  to  be  used  depends  on  the 
urgency  of  the  case.  This  estimate  is  made  on  a  drug  of  high  assay.  It  is 
unnecessary  to  slavishly  follow  the  rule,  but  the  rule  affords  an  excellent 
guide.  In  milder  cases  one  may  divide  the  total  dose  over  two  to  three 
days.  In  most  urgent  cases  the  total  dose  is  administered  in  12  to  16 
hours.  Assuming  that  the  drug  is  given  by  the  mouth  one  may 'expect  to 
see  clinical  results  in  12-36  hours.  In  many  cases  of  long  duration  the 
total  quantity  of  digitalis  given  to  attain  desired  results  may  amount  to 
50  or  60  grains  over  a  period  of  five  to  ten  days  and  not  infrequently  I 
have  given  much  larger  total  doses  with  benefit.  We  must  not  consider 
too  closely  a  limitation  of  dosage  expressed  in  figures,  but  administer  the 
drug  until  the  desired  results  are  obtained  or  some  evidence  of  digitalis 
intoxication  is  manifested.  To  illustrate  this  dosage  concretely  one 
would  give  an  adult  patient  of  average  weight,  disregarding  the  excess 
of  weight  in  stout  individuals,  30  grains  or  300  minims  of  the  tincture  in 
the  24-36  hours.  The  first  dose  would  contain  10-15  grains  or 
100-150  minims,  followed  in  4-6  hours  by  5-7  J/£  grains  or  50-75 
minims  of  tincture,  followed  at  4-6  hour  intervals  by  2  grains  or  20 
minims.  In  this  way  it  will  be  seen,  using  the  larger  doses  at  shorter 
intervals,  that  the  whole  dose  is  administered  in  12-16  hours;  using  the 
smaller  doses  and  longer  interval^,  administered  in  48  hours.  Many  of 
the  older  writers  have  maintained  that  digitalis  exerted  no  influence  on 
the  heart  in  febrile  conditions;  that  the  heart  was  not  slowed  and  that 
there  was  no  improvement  observed  clinically.  I  believe  these  conclu- 
sions were  based  upon  an  entirely  inadequate  dosage.  When  these  larger 
doses  are  given  the  heart  may  be  distinctly  slowed,  though  slowing 
does  not  always  occur.  Clinical  improvement,  that  is,  evidence  of  a 
more  efficient  circulation,  a  better  quality  of  the  pulse  and  better  char- 
acter of  heart  sounds  are  among  the  commonest  of  observations.  More- 
over, there  is  electrocardiographic  evidence  that  the  drug  is  in  actual 
combination  with  the  heart  muscles  by  the  delayed  conduction  and 
deformity  in  the  "T"  wave.  I  believe  that  Cohn  is  right  in  expressing 
his  belief  that  there  is  no  difference  in  the  principle  in  the  way  digitalis 
acts  in  febrile  and  non-febrile  cases. 

If  the  circulatory  condition  of  the  patient  when  first  seen  denotes  great 
peril  or  if  the  circulation  becomes  rapidly  bad  the  drug  not  having  been 
previously  administered,  one  must  have  recourse  to  other  than  mouth 
administration  to  obtain  results. 

If  for  any  reason  the  drug  may  not  be  given  by  the  mouth,  it  may 
be  given  by  the  rectum,  in  starch  paste  or  in  warm  milk,  4  or  5  ounces, 
an  amount  that  is  readily  retained. 

If  digitalis  is  given  for  a  considerable  period  by  this  method  it  is 


PNEUMONIA  173 

better  to  give  the  daily  dosage  in  one  injection  or  at  the  most  two,  be- 
cause more  frequent  administration  may  render  the  rectum  intolerant 
and  the  rate  of  absorption  is  so  slow  that  there  is  no  danger  of  toxic 
results  from  the  size  of  the  dose.  If,  when  first  seen  the  circulation  is 
sadly  impaired  or  the  crisis  is  near  at  hand,  at  which  time  we  are  more 
concerned  with  the  possibility  of  circulatory  collapse,  I  prefer  to  begin 
the  administration  with  strophanthin  given  intramuscularly  or  intra- 
venously. Strophanthus,  although  in  no  way  allied  botanically  or  chem- 
ically to  digitalis  is  pharmacologically  almost  identical,  so  that  in  ad- 
ministering strophanthus  or  its  active  principle,  we  may  think  entirely 
in  terms  of  digitalis  as  regards  rate  of  absorption  and  elimination;  how- 
ever, these  two  drugs  differ  materially.  Given  by  the  mouth  the  official 
preparation,  tincture  of  strophanthus,  gives  varying  and  uncertain 
results  entirely  due  to  the  variability  in  its  absorption.  Hatcher  has 
estimated  that  the  average  dose  of  strophanthin  given  by  the  mouth  to  be 
therapeutically  efficient  is  ten  times  the  dose  given  under  the  skin  or  into 
a  vein.  Often  a  very  large  part  of  the  drug  so  administered  can  be  re- 
covered unabsorbed  while  again  very  rapid  absorption  with  dangerous  or 
fatal  issue  may  occur.  This  latter  accident  would  seem  to  be  more  com- 
mon in  conditions  of  congestion  of  the  gastro-intestinal  canal.  For  these 
reasons  I  never  prescribe  strophanthus  or  strophanthin  by  the  mouth 
and  advise  strongly  against  it.  There  are  several  varieties  of  strophan- 
thus in  use  only  one  of  which,  strophanthus  Hispidus  or  Komb6  are 
official.  The  official  strophanthin  derived  from  this  drug  is  an  amor- 
phous body,  a  reliable  product,  but  not  as  active  nor  as  constant  in  its 
composition  as  the  crystalline  strophanthin  recovered  by  the  process  of 
Thorns  from  strophanthus  gratus,  called  strophanthin  G  or  crystalline 
strophanthin  of  Thorns,  which  is  said  to  be  identical  with  ouabain. 

Strophanthin,  the  nature  of  which  is  not  specified,  or  strophanthin 
under  proprietary  names  the  assay  of  which  is  not  specified  should  not  be 
used.  In  my  own  experience  the  amorphous  strophanthin  of  the  phar- 
macopoeia administered  intramuscularly  or  subcutaneously  has  caused 
much  irritation  about  the  site  of  injection,  but  the  amorphous  strophan- 
thin prepared  under  the  name  of  Strophanthin  Boehringer  and  handled 
by  Merck  supplied  in  individual  ampoules,  containing  1  c.c.  of  a  solution 
of  1  milligram  of  the  glucoside  has  rarely  caused  irritation  in  my  hands. 
Of  late  ouabain  or  the  crystalline  strophanthin  of  Thorns  has  been  pre- 
pared by  different  American  drug  houses  in  solution  in  ampoules,  usually 
containing  ^  milligram.  These  preparations,  so  far  as  my  experience 
has  gone  with  them  have  been  reliable.  As  determined  by  physiological 
assay  by  the  cat-heart  method  of  Hatcher  ouabain  given  intramuscu- 
larly is  about  twice  as  strong  as  the  amorphous  strophanthin;  when  both 


174  TREATMENT  OF  ACUTE  INFECTIOUS  DISEASES 

are  given  intravenously  about  1.3  times  as  strong.  This  difference  de- 
termined by  the  mode  of  administration,  is  probably  due  to  the  difference 
in  rate  of  absorption.  It  is  very  important  that  we  should  realize  the 
difference  in  potencies  of  these  two  forms  of  sfrophanthin. 

Ouabain  is  three  times  as  active  as  digitoxin  when  administered  intra- 
venously. These  statements  are  based  on  personal  communication  from 
Dr.  Hatcher.  It  has  been  estimated  by  Hatcher's  method  that  0.35  mg. 
of  digitoxin  of  Merck  is  equal  to  100  mg.  of  digitalis  leaf,  i.  e.,  digitoxin  is 
about  300  times  as  strong  as  digitalis  leaf.  According  to  these  figures, 
then,  strophanthin  is  about  900  times  as  potent  as  digitalis  leaf.  One 
mg.,  then,  of  crystalline  strophanthin  or  ouabain  would  equal  some 
13-14  grains  of  digitalis  leaf,  while  the  amorphous  atrophanthin  admin- 
istered by  vein  would  be  equal  to  between  10-11  grains.  It  must  be 
remembered  that  these  figures  are  not  mathematically  accurate,  but 
nevertheless  serve  as  useful  guides. 

When  given  intramuscularly  strophanthin  effects  may  be  looked  for  in 
2-3  hours;  when  by  the  vein,  immediately.  Our  dosage,  then,  in  the  case 
under  discussion  would  be  1  mg.  of  the  amorphous  strophanthin  or  Y^  mg. 
of  the  crystalline  strophanthin  into  the  muscle;  doses  equivalent  to  about 
10  grains  of  digitalis.  In  four  or  six  hours  Yi  this  dose  may  be  given.  In 
these  urgent  cases  one  should  begin  at  once  the  administration  of  the 
digitalis  by  the  mouth  according  to  the  Eggleston  rule  given  above. 
Strophanthin  is  rapidly  excreted  for  the  most  part  in  36  hours.  Digitalis 
is  slowly  absorbed  by  the  mouth,  it  requiring  12-16  hours  even  in  these 
large  doses  to  take  effect  so  that  one  may  say  that  the  digitalis  action 
catches  up  with  and  carries  on  that  of  the  strophanthin.  In  the  most 
urgent  cases  and  this  particularly  where  edema  of  the  lung  obtains  one 
uses  the  drug  intravenously,  the  dosage  being  about  3/4  of  that  given 
by  the  muscle,  although  I  very  frequently  give  the  same  dose  by  the  vein 
as  by  the  muscle,  providing  that  no  digitalis  has  been  given  before  and 
that  there  are  no  evidences  in  the  history  or  cardiac  examination  of  par- 
tial heart  block.  If  digitalis  has  been  previously  administered,  one  must 
try  to  determine  how  much  has  actually  been  taken,  reckoning  the 
tincture  as  10  per  cent,  of  digitalis  and  the  infusion  as  about  7  grains  to 
the  ounce  and  allowing  elimination  at  about  the  rate  of  1  1/2  grains  a 
day,  making  due  allowance  for  the  amount  accumulated  and  erring  on 
the  side  of  a  conservative  dosage  one  may  proceed  with  administration 
of  strophanthin. 

If  strophanthin  is  not  at  hand,  one  may  use  digitoxin  for  intravenous 
medication.  It  is  too  irritating  for  subcutaneous  or  intramuscular  in- 
jection. One  dissolves  the  digitoxin  in  1  c.c.  of  alcohol  and  dilutes  four 
times  with  sterile  water  for  the  intravenous  injection.  The  dosage 


PNEUMONIA  175 

to  get  equivalent  effects  would  be  three  times  that  of  the  strophanthin, 
i.  e.,  1  mg.  to  1  1/2  mg  or  1/60-1/40  grain  for  the  initial  dose;  one-half  of 
that  for  the  second  dose  in  4-6  hours.  The  tincture  of  digitalis  diluted 
in  the  same  way  with  water  may  be  used  intravenously,  the  doses  being 
40-60  minims.  These  intravenous  doses  are  followed  by  oral  adminis- 
tration as  above.  The  therapeutic  effect  is  shown  by  the  general  im- 
provement in  the  patient,  relief  of  congestion,  better  quality  of  pulse  and 
respiration,  improvement  in  the  heart  sounds  and  in  spite  of  many  state- 
ments to  the  contrary,  very  frequently  a  definite  slowing  of  the  pulse.  I 
have  seen  a  patient  with  a  temperature  between  105°  and  106°  F.  on  the 
day  before  her  crisis,  after  a  careless  or  reckless  dosage  of  strophanthin, 
with  a  pulse  of  70,  which  on  the  day  after  the  crisis  fell  to  40  and  was 
probably  in  block.  I  may  add  that  at  no  time  was  there  anything  but 
benefit  seen  even  from  such  an  unwarranted  dosage.  The  signs  of  digi- 
talis accumulation  or  poisoning  are  gastro-intestinal  irritation,  especially 
vomiting,  but  one  must  be  cautious  not  to  mistake  the  vomiting  which 
may  occur  with  a  severe  pneumonia,  especially  an  influenzal-pneumonia 
for  the  effects  of  digitalis.  I  have  seen  a  very  excellent  man  stop  the 
digitalis  in  such  a  case  with  diagnosis  of  digitalis  intoxication  on  an 
accumulation  of  7  grains.  Undue  slowing  of  the  heart,  evidences  of  heart 
block,  premature  systoles  coming  on  during  administration  of  the  drug 
may  all  be  looked  upon  as  expressions  of  digitalis  intoxication,  but  pre- 
mature systoles  may  occur,  and  heart  block  as  well,  as  the  expression  of 
toxins  on  the  heart.  A  cardiogram  in  one  instance  demonstrated  that 
the  coupled  beats  (a  rare  phenomenon  in  a  regularly  beating  heart)  which 
was  attributed  to  digitalis  were  premature  systoles  from  the  auricle 
while  digitalis  coupling  is  almost  always  due  to  premature  systoles  from 
the  ventricle.  Far  more  damage  is  done  by  the  neglect  of  sufficient 
dosage  or  to  excessive  timidity  than  is  done  by  overdosage. 

If,  as  rarely  occurs,  the  pulse  drops  abruptly,  becomes  irregular, 
betokening  a  heart  block,  atropine  sulphate  in  doses  of  one  hundredth  of 
a  grain  (0.0006  Gm.)  should  be  given  hypodermically  or  intramuscularly, 
which  will  usually  promptly  relieve  the  block,  although  its  recurrence  as 
the  atropine  effect  wears  off  may  necessitate  repetition  of  the  doses  at 
three  or  four  hour  intervals.  This  is  such  a  rare  occurrence  (and  I  have 
never  seen  it  in  an  acute  febrile  process),  that  it  should  not  lead  one  to 
hesitate  in  the  use  of  the  drug. 

I  will  mention  other  so-called  cardiac  stimulants,  such  as  convallaria 
and  sparteine,  only  to  condemn  them,  as  neither  their  pharmacology  nor 
their  therapeutic  application  has  been  worked  out  and  in  the  case  of 
sparteine,  we  have  reason  to  believe  that  we  are  handling  a  drug  which  is 
rather  a  depressant  than  a  stimulant. 


176  TREATMENT  OF  ACUTE  INFECTIOUS  DISEASES 

If  proper  administration  of  the  digitalis  series  is  not  provocative  of  a 
satisfactory  result  or  if  for  any  reason  they  cannot  be  given  or,  if  the 
demands  are  urgent  before  the  drug  has  an  opportunity  to  take  effect, 
one  has  recourse  to  the  vaso-motor  stimulants:  Among  these  may  be 
mentioned  caffeine,  camphor,  strychnine  and  adrenalin. 

I  am  growing  more  and  more  to  distrust  the  value  of  the  drugs  men- 
tioned for  the  purpose  specified  with  exception  perhaps  of  adrenalin. 
Caffeine  has  been  very  much  used.  One  can  usually  demonstrate  in 
the  presence  of  a  low  blood  pressure  a  fairly  constant  response  varying 
from  10  to  20,  rarely  more,  millimeters  of  mercury.  This  occurs  within  a 
few  minutes,  lasts  but  a  few  minutes  and  the  effects,  as  a  rule,  are  gone  in 
twenty  minutes  to  a  half  hour  and,  in  a  few  instances,  after  a  longer 
period.  It  would  seem  to  me  like  the  application  of  a  whip  to  a  tired 
horse.  No  such  sustained  effects  can  be  demonstrated  as  after  exposure 
to  the  cold  fresh  air. 

If  used  the  drug  should  be  given  in  large  doses,  gr.  iii  to  gr.  v  (0.20  to 
0.30  Gm.)  of  a  double  salt  either  of  sodium  salicylate  or  sodium  benzoate 
which  are  readily  soluble  in  water.  This  may  be  injected  or  given 
hypodermically  or,  better  yet,  intramuscularly  at  four-hour  intervals, 
or  in  urgent  cases,  at  three-hour  intervals  or  two-hour  intervals.  It  is 
maintained  by  some  clinicians  that  larger  doses  are  needed  by  coffee 
drinkers  than  for  those  who  abstain,  which  seems  a  reasonable  assump- 
tion (Bethea).  Given  in  the  form  of  coffee  by  the  rectum,  in  cases  of 
threatened  collapse  it  is  of  peculiar  value,  when  its  effects  are  enhanced 
by  those  of  heat.  The  action  of  the  drug  is  upon  the  vaso-motor  centres. 
How  much  effect  it  has  upon  the  heart  output  has  never  been  satisfac- 
torily determined. 

I  have  seen  peculiar  results  ensue  after  a  single  dose  of  caffeine  to 
patients  with  digitalis  accumulation,  rapid  pulse  and  respiration,  great 
mental  perturbation  and  the  appearance  of  collapse.  I  no  longer  order  it 
for  patients  under  digitalis  medication.  Moreover,  caffeine  renders  many 
patients  wakeful,  a  most  undesirable  result  in  pneumonia.  Under  no 
circumstance  should  it  be  administered  in  place  of  the  digitalis  series. 

Camphor,  too,  I  use  in  a  goodly  dosage,  if  I  use  it  at  all,  giving  3  to  5 
grains  (0.20  to  0.30  Gm.)  and  preferably  5,  hypodermically  or  intramus- 
cularly. The  best  mode  of  administration  is  in  a  10  per  cent,  or  20  per 
cent,  solution  in  oil.  Sesame  oil  makes  an  excellent  vehicle.  Camphor 
has  recently  been  put  on  the  market  in  mineral  oil  with,  in  some  instances 
lamentable  results.  The  mineral  oil  is  not  absorbed,  acts  as  a  foreign 
body  irritant,  causing  chronic  inflammation  of  the  tissues  about  the  site 
of  injection  and  the  oil  finding  its  way  into  the  tissues  adjacent  may  give 
rise  to  extensive  inflammation  or  even  necrosis.  The  results  are  akin  to 


PNEUMONIA  177 

the  more  familiar  ones  following  paraffin  injections.  The  practitioner 
should  not  use  these  preparations  so  attractively  offered  to  the  profes- 
sion. 

Camphor  is  given  at  four-hour  intervals  or  in  urgent  cases  at  three  to 
two-hour  intervals;  indeed,  one  may  alternate  caffeine  and  camphor  in 
the  doses  specified,  so  that  one  or  the  other  drug  is  given  at  two-hour 
intervals. 

In  strychnine  I  have  but  little  faith,  as  a  circulatory  stimulant.  I 
will  not,  however,  oppose  the  usage  of  its  earnest  advocates  so  far  as  to 
condemn  it.  Again  it  should  never  be  used  as  a  substitute  for  digitalis. 
If  the  drugs  mentioned  fail  it  may  be  tried,  in  doses  of  gr.  1/30  to  gr.  1/40 
(0.002  to  0.0015  Gm.)  hypodermically  or  intramuscularly,  at  intervals 
of  three  or  four  hours. 

Adrenalin  chloride  or  epinephrin.  Epinephrin  is  the  most  power- 
ful vaso-motor  stimulant  that  we  have,  but  its  effects  are  very  short- 
lived. It  is  indicated  in  urgent  cases  or  in  cases  of  collapse,  and  I  have 
found  its  use  of  great  value.  Hypodermically  its  effects  are  uncertain; 
intramuscularly  fairly  certain  and  then  may  be  given  in  doses  of  m.  x  to 
m.  xv  (0.60  to  1  c.c.).  Given  into  the  vein  its  effects  are  immediate, 
out  of  all  proportion  to  its  usage  elsewhere.  Only  3  or  4  minims  (0.20  or 
0.25  c.c.)  should  be  put  into  the  vein.  I  have  seen  a  pressure  of  60 
millimeters  rise  to  over  200  faster  than  the  measurement  could  follow  it, 
throwing  a  tremendous  and  sudden  burden  on  the  heart.  It  cannot  take 
the  place  of  the  other  drugs  for  continued  usage. 

Nitroglycerin,  too,  has  been  used,  but  I  decry  it,  for  its  physio- 
logical action  is  to  heighten  the  very  effects  we  desire  to  overcome,  for  it 
is  a  vaso-motor  depressant,  causing  dilatation  of  the  vessels.  The  only 
justification  for  its  use  is  in  the  case  for  excessive  hypertension  with 
edema  of  the  lungs.  In  cases  of  marked  essential  hypertension  the  re- 
sults are  sometimes  magical  in  their  promptness. 

Alcohol,  too,  I  condemn,  for  the  reasons  specified  in  Typhoid  Fever 
(Chap.  XIV). 

To  reiterate,  then,  success  depends  on  an  early  appreciation  of  circula- 
tory distress,  the  use  and  liberal  use  of  the  digitalis  series. 

Collapse.  This  accident  is  more  likely  to  occur  at  or  near  the  crisis, 
although  it  may  possibly  occur  earlier. 

The  probability  of  collapse  is  lessened  in  those  cases  where  digitaliza- 
tion  of  the  heart  has  been  effected.  When  it  does  occur,  vigorous  stimu- 
lation is  indicated.  Heat  should  be  applied  to  the  surface  of  the  body, 
hot  water  bottles  at  the  feet,  hot  flannels  or  hot  cloths  applied 
to  the  extremities,  sufficient  number  of  blankets  put  upon  the  patient, 
volatile  stimulants,  such  as  the  stronger  water  of  ammonia  ap- 


178  TREATMENT  OF  ACUTE  INFECTIOUS  DISEASES 

plied  to  a  towel  and  given  to  inhale;  a  teaspoonful  of  aromatic  spirits  of 
ammonia  may  be  given  in  water,  this  in  turn  followed  by  the  injection 
of  the  most  rapidly  acting  vaso-motor  stimulants,  such  as  adrenalin, 
in  doses  of  rn.-xv  (1  c.c.)  intramuscularly  or  in.  lesser  doses  of  m.  iii-iv 
(0.20-0.25  c.c.)  into  a  vein.  This  may  be  followed  by  caffeine  or  cam- 
phor in  doses  of  gr.  v  (0.30  Gm.)  or  strychnine,  gr.  1/30  (0.002  Gm.), 
doses  into  the  muscles  or  a  vein  for  a  more  permanent  effect;  these  in 
turn  may  be  followed  by  strophanthin,  gr.  1/120  to  1/60  (0.0005 
to  0.001  Gm.)  down  into  the  muscle  or  into  the  vein,  and  this 
in  turn  by  a  digitalis  medication,  as  discussed  above  under  a  failing 
circulation. 

Heat  applied  to  the  bowel  is  also  of  importance  and  may  be  given 
in  the  shape  of  a  saline  irrigation  at  110°  F.  to  which  strong  black 
coffee  may  well  be  added. 

Pulmonary  Edema.  Pulmonary  edema  means  cardiac  distress 
and  vigorous  measures  should  be  taken  at  once  to  relieve  it. 

If  the  patient  is  plethoric,  full  blooded,  cyanotic,  much  of  the  burden 
may  be  taken  off  the  heart  by  venesection  of  12  to  16  or  more  ounces 
of  blood. 

•  It  has  been  our  plan  of  late  both  in  hospital  and  private  practice  to 
administer  at  once  intramuscularly  adrenalin  in  doses  of  15  minims,  at 
intervals  of  15  minutes  for  six  doses  if  necessary.  We  begin  at  the  same 
time  with  intravenous  doses  (preferably) ,  or  intramuscular,  of  strophan- 
thin 1/120-1/60  gr.  (0.0005-0.001  Gm.)  if  the  patient  has  not  already  had 
digitalis;  beginning  with  not  more  than  half  the  lesser  dose  above  men- 
tioned if  he  has  had  digitalis.  These  doses  are  those  of  amorphous 
strophanthin.  If  crystalline  strophanthin  or  ouabain  be  given,  the  dose 
should  be  1/2  to  3/4  of  that  specified.  This  has  proved  very  satisfactory 
in  our  hands.  We  have  seen  pulmonary  edema  clear  up  very  promptly 
under  adrenalin  alone  and  under  strophanthin  alone,  but  unfortunately 
many  cases  resist  one  or  both  drugs  and  all  other  drugs. 

Atropine  Sulphate  has  long  been  used  in  pulmonary  edema  in 
doses  of  gr.  1/100  (0.0006  Gm.)  hypodermically  or  intramuscularly. 
The  results  in  my  experience  have  not  been  satisfactory.  In  per- 
sons with  hypertension  nitroglycerin  may  give  magical  effects.  The 
rationale  rests  on  the  dilation  of  the  systemic  vessels  and  the  constric- 
tion of  the  vessels  in  the  pulmonary  circuit.  In  this  way  the  left  heart  is 
relieved,  and  pulmonary  edema,  so  far  as  it  is  dependent  on  circulatory 
conditions,  is  believed  to  be  caused  by  accumulation  in  the  pulmonary 
circuit  from  a  failing  left  heart  and  a  relatively  strong  right  heart.  But 
in  pneumonia  one  feels  convinced  that  pulmonary  edema  is  determined 
in  some  of  the  cases  by  the  effect  of  the  toxins  on  the  pulmonary  vessels 


PNEUMONIA  179 

and  so  far  as  this  is  true  would  lead  one  to  expect  less  from  the  circulatory 
stimulants  than  when  it  is  due  to  circulatory  inadequacy. 

A  measure  that  is  credited  with  some  degree  of  efficiency  is  a  dry 
cupping  of  the  chest  in  front  and  behind.  (For  technique,  see  above.) 
The  best  position  for  the  patient  is  a  semi-recumbent  one.  However  I 
have  always  been  impressed  with  the  amount  of  handling  necessary  to 
pursue  the  cupping,  as  in  itself  prejudicial. 

Dyspnoea.  Dyspncea  may  be  due  to  embarrassment  of  the  respi- 
ratory centre  or  to  shallow  respiration  induced  by  the  pain  of  pleurisy. 
In  the  latter  case  our  efforts  are  aimed  at  a  relief  of  the  pain.  It  is 
surprising  how  much  lung  tissue  may  be  involved  without  respiratory 
disturbance,  providing  the  toxemia  is  not  marked.  However,  very 
extensive  involvement  of  the  lung  must  induce  disturbance  of  breathing. 
It  has  been  most  gratifying  to  see  how  much  respiratory  distress  is 
relieved  by  submitting  the  patient  to  the  open-air  treatment. 

Inhalations  of  oxygen  are  used  for  the  same  purpose.  Every  now  and 
then  there  is  a  rapid  and  convincing  improvement,  during  the  inhalation 
of  oxygen.  Probably  the  success  of  oxygen  depends  on  the  concentra- 
tion, that  is,  the  oxygen  tension.  We  are  in  need  of  an  apparatus  by 
which  oxygen  may  be  administered  in  a  concentrated  form  without  such 
discomfort  to  the  patient  as  those  at  our  command  now  entail.  The 
simplest  form  would  be  to  administer  it  through  a  soft  rubber  funnel  with 
a  towel  to  prevent  the  escape  of  oxygen  between  it  and  the  face  or  the  use 
of  the  bag  ordinarily  employed  in  gas  anesthesia.  But  the  fact  is  the 
patient  illy  bears  these  procedures.  (For  further  technique  see  Influenzal 
Pneumonia,  Chap.  XII.  See  Summary.) 

Respiratory  embarrassmant  may  also  be  due  to  pulmonary  edema, 
when  it  is  to  be  treated  as  above  specified. 

Broncho-pneumonia.      (Pneumococcus  origin.) 

Specific  treatment  is  determined  by  the  same  technique  as  for  lobar 
pneumonia.  It  has  been  contended  that  the  nature  of  the  lesion  de- 
termined quite  a  different  line  of  treatment  and  that  broncho-pneumonia 
should  not  be  treated  like  lobar  pneumonia.  I  am  not  quite  in  accord 
with  this  teaching,  for  it  has  been  my  experience  that  a  large  per  cent,  of 
the  cases  of  broncho-pneumonia  have  greatly  benefited  by  the  open-air 
treatment.  I  am,  however,  appreciative  of  the  fact  that  broncho-pneu- 
monia is  peculiarly  prone  to  attack  the  aged  and  the  weak.  These  cases, 
certainly,  should  not  be  exposed  to  the  open  air,  unless  great  watchful- 
ness is  observed  to  keep  up  the  body  heat. 

If  the  technique  of  the  open-air  treatment  cannot  be  well  carried  out, 
these  cases  had  better  not  be  exposed.  Finally,  there  is  a  certain  number 
of  cases  in  whom  the  cough,  instead  of  being  improved  is  made  worse. 


180          TREATMENT  OF  ACUTE  INFECTIOUS  DISEASES 

These  cases  do  better  in  a  warmer  air  and  should  be  kept  in  a  room  with  a 
temperature  from  65°  F.  to  70°  F.,  the  air  of  which  is  renewed  from  time 
to  time.  This  class  of  cases  often  do  well  with  inhalations  of  steam  or 
medicated  steam,  such  as  has  been  specified  for  bronchitis. 

The  broncho-pneumonias  under  discussion  are  those  due  to  pneu- 
mococcus  or  to  the  streptococcus  and  influenza  bacillus  as-  ordinarily 
seen.  When  the  virulency  of  these  latter  organisms  is  so  great  as  to 
cause  such  epidemics  as  one  saw  the  streptococcus  induce  in  our  camps 
during  the  late  war  and  the  influenza  bacillus  send  sweeping  through  the 
camps  and  our  civil  population  as  well,  they  give  special  features  to  the 
broncho-pneumonia,  its  complications  and  sequelae  that  require  special 
consideration  which  will  be  found  under  the  headings  of  streptococcus 
and  influenzal-pneumonia. 

COMPLICATIONS  OF  PNEUMONIA 

Fluid  in  the  Chest.  Basing  one's  statement  on  autopsies  one 
may  say  that  fluid  in  the  chest  is  a  very  common  happening  during  or 
following  lobar  pneumonia. 

Lord  states  that  a  small  and  varying  amount  of  fluid  was  present 
in  37%  of  a  series  of  autopsies  quoted  by  him.  These  small  collections, 
however,  are  rarely  recognized  during  life  so  that  the  percentage  of  cases 
on  which  a  diagnosis  may  be  made  during  life  is  relatively  small,  but 
actually  contribute  a  considerable  number. 

Norris  in  Modern  Medicine,  collecting  24,011  cases  found  pleural 
effusion  in  6.2  per  cent.  His  figures  in  autopsy  cases  agree  fairly  well 
with  Lord,  he  giving  41.8  per  cent,  in  nearly  1,000  autopsies.  If  the 
statement  that  at  least  400  c.c.  must  be  present  before  giving  physical 
signs  be  true  and  if  one  considers  the  difficulty  in  interpreting  the  phys- 
ical signs  of  small  collections  of  fluid  in  pulmonary  consolidation,  the 
discrepancy  of  these  figures  is  readily  understandable.  In  over  13,000 
cases  collected  by  Norris,  the  fluid  was  purulent,  that  is,  constituted  an 
empyema  in  the  clinical  sense,  in  2.2  per  cent.,  while  in  autopsy  findings 
in  nearly  1,000  cases  was  a  little  over  5  per  cent. 

If,  then,  during  a  pneumonia,  there  is  an  increase  in  pleural  pain,  cough 
and  dyspnoea,  if  there  is  an  accession  of  temperature,  a  rise  in  pulse  rate 
and  respiration  one  should  think  of  the  possibility  of  an  accumulation 
of  fluid.  There  may  be  a  change  in  the  physical  signs  suggestive  of  fluid, 
one  may  get  a  flatness  and  absence  of  breathing  over  fluid  or  one  may 
find  bronchial  voice  and  breathing  and  this  latter  particularly  in  chil- 
dren. A  displacement  of  the  heart,  more  readily  determined  by  a  right- 
sided  effusion  or  a  well-defined  paravertebral  triangle  of  dulness  (Grocco's 


PNEUMONIA  181 

sign)  increases  the  possibility  of  an  effusion.  Furthermore,  if  the  tem- 
perature is  maintained  beyond  the  period  of  anticipated  crisis  an  effusion 
is  the  most  probable  explanation. 

Under  these  circumstances  an  exploratory  puncture  should  be  made. 
(For  technique  see  Index.)  When  a  portable  X-ray  apparatus  is  at  hand 
a  Roentgenological  examination  should  be  made.  Large  collections  of 
fluid  of  course  lessen  the  respiratory  space  and  by  increased  thoracic 
pressure  and  displacement  of  the  heart  further  interfere  with  the 
circulation. 

The  indications,  then,  are  such  pressure  symptoms,  dyspnoea,  cyanosis 
and  cardiac  weakness.  Even  without  these  symptoms  marked  displace- 
ment of  the  heart  or  an  effusion  beyond  two  to  three  weeks'  duration 
should  indicate  the  procedure.  Moreover,  increasing  pressure  upon  the 
lung  favors  thrombosis  and  embolism,  while  thickening  of  the  pleura 
and  adhesions  are  more  likely  to  ensue.  For  this  reason  paracentesis  is 
indicated.  (For  technique  see  below.)  (For  the  treatment  of  symptoms 
incident  upon  the  effusion  see  Chap.  VIII.) 

Much  more  serious  than  a  serofibrinous  effusion  is  the  pleural  effusion 
constituting  an  empyema. 

Whenever  after  Defervescence  the  temperature  and  pulse  begin 
to  rise  and  so  continue  or  whenever  the  temperature  is  maintained 
beyond  the  anticipated  crisis,  one  should  always  consider  empyema  the 
most  probable  explanation.  While  septic  endocarditis,  thrombosis, 
phlebitis,  abscess  of  the  lung,  otitis  and  antral  involvement  and  other 
less  common  complications  may  be  the  cause,  the  frequency  of  the 
empyema  is  to  be  suspected  even  in  the  absence  of  physical  signs  and 
repeated  and  assiduous  search  should  be  made  for  sacculations  of  pus  and 
the  frequency  of  such  sacculations  in  the  interlobar  fissure  would  indicate 
exploration  in  this  region,  when  any  signs  of  consolidation  persist  in  this 
neighborhood.  Furthermore  it  must  be  remembered  that  these  saccula- 
tions may  be  small  and  that  only  repeated  explorations  will  reward  the 
search.  The  Roentgen  ray,  of  course,  affords  material  assistance  in 
locating  many  of  these  collections.  When  pus  is  determined  evacuation 
is  called  for.  The  technique  of  the  procedure  of  thoracentesis  is  as 
follows : 

Apparatus : 

1.  95  per  cent,  alcohol  and  tincture  of  iodine. 

2.  1  per  cent,  cocaine,  hydrochloride  or  novocaine  solution. 

3.  Sub  Q  syringe  and  No.  20  needle. 

4.  Luer  syringe,  10-20  c.c. 

5.  Paracentesis  needle  or  a  lumbar  puncture  needle  to  fit  the  Luer 
syringe  and  provided  with  an  adapter  to  fit  rubber  tubing. 


182  TREATMENT  OF  ACUTE  INFECTIOUS  DISEASES 

6.  Two  pieces  of  rubber  tubing,  each  12  inches  long,  3  mm.  inside 
diameter  with  a  wall  sufficiently  stiff  to  resist  suction. 

7.  Potain  aspirating  set  or  other  similar  device. 

8.  Thick-wa'lled  bottle  of  any  size — 32  oz  is  convenient. 

9.  Sterile  gauze  and  adhesive  plaster  and  towels. 

10.  Sterile  gloves. 

11.  Three  sterile  test  tubes. 

One  should  first  of  all  assemble  the  aspirating  set  and  test  it  to  be  sure 
that  the  stopper  fits  the  bottle  tightly  and  that  all  the  rubber  connec- 
tions, adapters,  needles  and  pump  fit  properly  and  that  the  pump  is  so 
connected  as  to  create  suction  in  the  flask.  When  once  set  up  disconnect 
only  the  needle  for  sterilization. 

Procedure.  Observe  strict  asepsis.  The  apparatus  and  gloves  may 
all  be  sterilized  by  immersing  them  in  a  solution  of  mercuric  bichlorid 
1:1000  for  ten  minutes. 

By  physical  examination  one  outlines  the  position  of  the  fluid  and 
determines  the  site  of  puncture.  In  an  ordinary  accummulation  the  best 
site  is  at  the  angle  of  the  scapula  at  the  6th  to  the  8th  interspaces, 
depending  on  the  height  of  the  fluid.  In  sacculation  one  must  puncture 
over  the  point  of  greatest  dullness. 

Position  of  the  Patient  depends  on  his  condition :  if  he  has  no 
fever  and  his  cardiac  condition  is  good  he  may  sit  erect  in  bed  with  his 
hands  clasped  around  the  flexed  knees.  This  position  will  draw  the 
scapula  forward  and  increase  the  width  of  the  intercostal  spaces.  When 
the  general  condition  of  the  patient  is  questionable  or  the  patient  feels 
very  nervous  or  dizzy,  it  is  better  to  have  him  on  the  unaffected  side, 
propped  on  a  pillow  in  order  to  arch  the  lower  side  and  thus  increase  the 
intercostal  spaces  of  the  affected  side. 

When  the  patient  is  in  position,  cleanse  the  site  of  the  puncture  with 
95  per  cent,  alcohol,  paint  three  or  four  inches  with  tincture  of  iodine. 
The  operator  either  puts  on  sterile  gloves  or  paints  the  fingers  with 
tincture  of  iodine  after  a  thorough  scrubbing  with  soap  and  water. 
With  the  left  forefinger  locate  the  interspace  to  be  pierced  and  with  tinc- 
ture of  iodine  on  the  applicator  outline  a  circle  about  1  cm.  in  diameter 
with  its  centre  about  one-half  centimeter  from  the  upper  border  of  the 
lower  rib.  Infiltrate  this  area  with  sterile  1  per  cent,  cocaine  hydrochlo- 
ride,  or  1%  novocaine  taking  care  to  introduce  the  solution  intradermally 
and  not  subcutaneously.  Then  insert  the  needle  at  right  angles  to  the 
patient's  back  and  inject  the  cocaine  into  all  the  tissues  down  and  through 
the  pleura.  After  waiting  five  minutes,  introduce  the  paracentesis  needle 
(attached  to  the  Luer  syringe)  along  the  anesthetized  path-holding  it  at 
right  angles  to  the  patient's  back.  Use  a  constant  firm  pressure  with  a 


PNEUMONIA  183 

slight  boring  motion.  If  the  resistance  of  the  skin  is  strong,  nick  the 
skin  with  the  point  of  a  scalpel.  With  experience  one  soon  learns  the 
feeling  produced  by  piercing  the  pleura.  One  should  not  drive  the  needle 
in  suddenly  with  force  nor  any  further  in  the  cavity  than  is  necessary. 
As  soon  as  one  thinks  the  cavity  is  pierced,  try  to  withdraw  fluid  with  the 
syringe.  Remove  15-20  c.c.  of  fluid,  leave  the  needle  in  situ,  remove  the 
syringe  from  the  needle  and  distribute  the  fluid  among  the  three  sterile 
test  tubes  for  microscopical  and  bacteriological  examination.  Connect 
the  needle  immediately  with  the  adapter  and  rubber  tube  of  the  suction 
apparatus,  being  sure  it  is  on  the  suction  side.  (An  easy  test  is  to  dip  the 
adapter  in  a  dish  of  alcohol  and  release  the  valve  for  a  second  just  before 
connecting  the  needle.) 

Maintain  a  slow  stream  by  gentle  suction  until  the  patient  shows  signs 
of  distress,  such  as  cough,  faintness  or  pain,  or  until  1000  to  1500  c.c.  is 
removed.  Then  discontinue  the  process  and  withdraw  the  needle  a 
small  distance.  If  the  symptoms  abate  one  may  continue  cautiously 
until  the  symptoms  again  occur  or  until  the  flow  with  gentle  suction  is 
slight. 

Occasionally  flakes  of  fibrin  will  clog  the  needle  and  it  will  be  neces- 
sary to  stop  the  suction  and  let  a  small  amount  of  air  be  sucked  into  the 
cavity  or  introduce  a  stylet  into  the  needle.  To  remove  the  needle,  clamp 
off  the  rubber  tube  to  disconnect  the  suction,  then  quickly  withdraw  the 
needle  and  cover  the  puncture  at  once  with  sterile  gauze.  Move  skin 
about  puncture  back  and  forth  to  diminish  the  chance  of  the  entrance  of 
air.  Remove  excess  iodine  with  95  per  cent,  alcohol.  Apply  sterile 
gauze  with  adhesive  straps. 

In  case  one  gets  a  dry  tap  at  first,  one  cautiously  pushes  the  needle 
directly  in  with  the  suction  on.  At  any  time  fluid  runs  one  should  retain 
this  position  until  the  flow  ceases,  then  continue  to  slowly  push  the  needle 
inward  until  the  lung  is  touched.  If  no  flow  appears,  withdraw  the 
needle  part  way  and  tilt  it  toward  the  patient's  head  at  an  angle  of  about 
60  degrees  and  gradually  insert  it  as  before.  Repeat  this  process  cau- 
tiously, directing  the  needle  in  all  directions  until  fluid  is  obtained  or 
until  one  is  convinced  there  is  none  to  obtain  or  that  it  is  too  thick  to  run 
through  the  needle  being  used. 

It  may  be  necessary  to  make  a  second  puncture  at  a  different  level  or 
in  the  midaxillary  line  in  the  4th  or  5th  interspace;  and  it  may  be  wise 
to  use  a  larger  needle  the  second  time. 

The  Amount  to  be  Withdrawn  varies  with  each  individual  case. 
One  must  be  guided  by  the  reaction  of  the  patient.  If  the  patient  coughs, 
has  pain  or  feels  faint  one  should  shut  off  the  suction  at  once  as  described 
above.  The  rate  of  withdrawal  is  more  important  than  the  volume  and 


184          TREATMENT  OF  ACUTE  INFECTIOUS  DISEASES 

should  be  slow  enough  to  allow  the  circulation  in  the  lungs  and  the 
expansion  of  the  lungs  to  readjust  themselves. 

Forscheimer  says  that  too  rapid  aspiration  results  in  an  acute  con- 
gestion of  trie  lungs  and  a  resulting  stimulation  of  the  vagus  nerve  that 
may  cause  syncope  or  even  sudden  death. 

Caution  should  be  taken  to  avoid  scraping  the  visceral  pleura  or 
piercing  the  lung  tissue  with  the  point  of  the  needle  and  thus  injure  the 
vagus  nerve  fibres,  causing  reflex  stimulation  that  is  carried  to  the  heart 
and  may  result  in  sudden  death. 

If  the  puncture  is  made  too  low  the  diaphragm  may  be  pierced.  If  one 
does  not  keep  close  to  the  upper  border  of  the  lower  rib  he  may  pierce  the 
intercostal  vessels  and  nerves  that  run  in  the  groove  on  the  lower  surface 
of  the  upper  rib. 

Pericarditis.  Quoting  Norris  in  Modern  Medicine,  pericarditis 
occurred  in  12.2  per  cent,  of  his  autopsies,  and  in  40,000  cases  of  pneu- 
monia 2.2  per  cent,  of  pericarditis  was  determined  clinically.  Pleurisy 
is  nearly  always  coincident  with  the  pericarditis.  Autopsy  records  show 
the  purulent  exudate  almost  but  not  quite  as  frequent  as  the  sero-fibri- 
nous.  This,  of  course,  in  no  way  represents  the  frequency  in  all  cases  of 
pneumonia.  The  physical  signs  are  those  of  pericarditis  from  any  other 
cause.  The  most  important  are  the  diminution  or  disappearance  of 
cardiac  impulse  or  increase  of  flatness  and  area  of  cardiac  dulness.  With 
this  may  be  heard  pericardial  friction  sounds,  though  these  may  be 
absent  in  a  large  degree;  dyspnoea  and  cyanosis  with  increasing  circula- 
tory embarrassment.  X-ray  examination  affords  assistance.  When 
these  evidences  of  circulatory  difficulties  are  determined,  an  exploratory 
puncture  is  indicated. 

The  best  site  for  paracentesis  may  be  determined  as  follows : — outline 
the  left  border  of  cardiac  dulness;  locate  by  palpation  or  auscultation 
the  apex  beat,  go  in  in  the  5th  space  between  these  two  points  about  J/£ 
inch  inside  the  limit  of  dulness.  At  this  site  one  is  less  likely  to  strike 
the  heart  and  should  he  do  so  comes  into  contact  with  the  thick  wall  of 
the  ventricle.  Other  sites  recommended  are,  first,  the  right  edge  of  the 
sternum,  about  1  inch  out  in  the  5th  space.  This  is  the  site  of  the  cardio- 
hepatic  angle  often  rendered  obtuse  by  the  collection  of  fluid.  The 
objection  to  this  site  is  that  in  case  of  error  in  diagnosis  one  strikes  the 
auricle.  This,  though  by  no  means  a  fatal  accident,  is  best  avoided. 
(2)  The  angle  between  the  xiphoid  cartilage  and  the  cartilaginous 
attachment  of  the  last  rib  on  the  left,  passing  the  needle  to  the  posterior 
border  of  the  xiphoid  and  then  turn  it  upwards  and  sharply  to  the  left. 
This  enters  the  dependent  part  of  the  pericardial  sac.  The  objections 
are  that  it  may  hit  the  internal  mammary  artery  or  the  heart.  (3)  The 


PNEUMONIA  185 

left  of  sternum  in  the  5th  space  either  close  to  the  sternum  or  an  inch 
to  an  inch  and  a  half  out,  to  avoid  the  internal  mammary  artery.  One 
can  use  a  weak  solution  of  cocaine  or  1  per  cent,  novocaine  or  may  freeze 
the  part  with  ethylchloride.  If  the  skin  is  thick  it  is  well  to  make  a  tiny 
incision  for  the  needle.  If  the  fluid  is  sero-fibrinous  one  may  proceed  to 
aspiration.  This  may  be  done  with  the  aspiration  needle  attached  to  a 
Potain  aspirator  or  other  device.  The  fluid  should  be  drawn  slowly  and 
if  this  precaution  is  observed,  it  may  be  removed  as  completely  as  pos- 
sible. The  tap  against  the  heart  can  be  readily  appreciated  and  the 
needle  withdrawn.  All  this  is  to  be  done  with  strict  surgical  asepsis. 
If  the  fluid  is  purulent,  it  becomes  a  surgical  problem.  The  sac  is  opened 
and  evacuated.  The  incision  is  1J^  inches  from  the  sternum  in  the 
5th  space. 

Small  collections  of  fluid  do  not  require  aspirations.  Local  treatment 
may  be  instituted  to  afford  comfort,  lessen  pain  and  precordial  distress. 
The  three  traditional  measures  are  the  application  of  cold,  heat,  and 
countei  irritation.  Cold  gives  the  best  results  as  a  rule.  It  is  applied 
by  means  of  an  ice  bag,  the  Leiter  coil  or  cold  compress. 

The  Bag.  The  circular  ice  bag,  commonly  made  with  a  metal 
cap  is  probably  the  best  for  the  purpose.  Ice  is  cracked  in  pieces,  not 
larger  than  the  end  of  one's  thumb  and  introduced  in  quantities  sufficient 
to  cover  the  bottom  of  the  ice  bag.  Just  enough  water  is  added  to  cover 
the  ice.  The  air  is  then  expelled  by  flattening  the  bag  until  the  water 
appears  at  the  opening.  The  cap  is  then  screwed  on  and  the  bag  will  be 
found  to  be  flaccid  and  readily  applied  to  the  chest  of  any  contour.  As 
it  is  not  easy  to  retain  the  ice  bag  in  position  without  some  device  and  the 
patient  is  annoyed  by  its  slipping  or  fatigued  by  the  constant  effort  to 
replace  it,  one  may  avoid  the  discomfort  by  suspending  the  bag  in  a 
long  strip  of  muslin  or  cheesecloth  folded  once  lengthwise  and  fastened 
around  the  opposite  shoulder  by  a  split  in  the  end  of  the  cloth.  Safety 
pins  retain  this  bag  in  position  in  the  bandage. 

Before  applying  the  ice  bag  the  skin  is  lubricated  with  a  simple  oil  or 
vaseline  and  the  bag  covered  by  a  cloth.  At  first  it  is  applied  inter- 
ruptedly for  an  hour  at  a  tune,  later  for  longer  periods  and  finally  con- 
tinuously. The  skin  should  be  watched,  for  too  great  cold  for  a  long 
period  may  damage  that  structure.  The  custom  of  adding  salt  to  the 
ice  is  to  be  deprecated. 

The  Leiter  tube  is  simply  a  coil  of  rubber  tube  coiled  like  an  old  fash- 
ioned lamp  mat,  one  end  connected  with  a  reservoir  of  water  above  the 
level  of  the  bed  and  the  other  with  a  receptacle.  The  water  is  allowed 
to  run  through  this  continuously  or  interruptedly. 

The  Cold  Compress  is  made   by   wringing   out   layers    of   old 


186  TREATMENT  OF  ACUTE  INFECTIOUS  DISEASES 

muslin  in  water  at  60°  F.  and  applied  simply  to  the  chest  and  covered 
by  flannel  and  renewed  every  hour.  These  applications  often  afford 
relief  for  the  pain  and  a  sedative  for  the  patient  and  often  bring  about  a 
slowing  of  the  heart. 

Heat.  The  simplest  method  of  applying  heat  is  by  the  hot  water 
bag.  Care  should  be  taken  to  fill  the  bag  not  more  than  half -full  and  to 
remove  all  the  air  from  the  bag  by  pressing  the  bottom  of  the  bag  flat 
until  the  water  fills  the  mouth  of  the  bag.  Then  insert  the  stopper;  thus 
the  bag  will  not  be  so  heavy  and  be  easily  adapted  to  any  contour.  The 
temperature  of  the  bag  should  be  tested  and  the  bag  either  covered 
by  a  towel  or  a  flannel  cover  to  avoid  burning  the  patient,  who  is  often 
unconscious. 

Hot  compresses  may  be  utilized. 

Cloths,  the  size  of  the  site  to  be  covered,  are  folded  so  that  they 
may  be  easily  unrolled  and  are  dropped  into  very  hot  water  (125°- 
150°  F.),  removed  with  a  stick  and  dropped  into  a  bath  towel  and  wrung 
out  by  twisting  the  ends  of  the  towel  in  different  directions.  Test  the 
temperature  on  your  own  cheek  before  applying  to  the  chest.  Lay  them 
gently  on  the  precordium  and  cover  them  with  a  towel  or  small  blanket 
and  leave  until  they  cool.  Repeat  until  you  are  sure  that  you  are  either 
obtaining  what  is  desired,  or  are  accomplishing  nothing.  The  Elec- 
tric Pad  is  suitable  for  the  purpose  and  convenient. 

Poultices.  Application  of  the  poultice.  Take  three  cups  of  water 
and  two  and  one-half  cups  of  flaxseed  meal.  Bring  the  water  to  a  boil 
and  add  the  meal  slowly,  stirring  it  all  the  time  with  a  spoon.  When  the 
mixture  is  so  thick  that,  poured  from  a  spoon  it  falls  drop  by  drop,  it  is 
beaten  quickly  to  make  it  light  and  then  is  spread  evenly  over  a  muslin 
or  gauze,  being  made  about  one-quarter  inch  in  thickness.  A  margin  of 
gauze  of  some  two  inches  should  be  left  all  around  to  turn  back  over  the 
edge  of  the  poultice.  The  poultice  is  then  covered  with  gauze,  this  being 
cut  to  have  a  margin  of  three  inches  to  fold  in  and  turn  under  the  muslin, 
between  it  and  the  protector.  The  protector  is  usually  a  piece  of  oil-silk 
or  old  flannel  which  serves  to  keep  in  the  heat.  A  binder  is  placed  under 
the  patient  and  a  poultice  is  brought  to  him  on  a  hot  plate  to  keep  it 
warm;  the  heat  is  tested  against  the  face  of  the  nurse,  to  determine  that 
it  is  not  so  hot  as  to  burn  the  patient;  it  is  then  applied  slowly,  so  that 
the  heat  can  be  better  borne  and  the  binder  brought  up  around  the 
poultice. 

The  poultice  should  not  be  kept  on  longer  than  an  hour,  because  it 
grows  cold  by  that  time,  unless  some  device  like  a  hot  water  bottle, 
partially  filled  to  avoid  weight,  or  a  Japanese  hand  stove  is  applied  to  it 
to  keep  the  heat  up.  When  the  poultice  is  removed  the  site  of  its 


PNEUMONIA  187 

application  is  smeared  with  oil  or  vaseline  and  covered  with  a  dry 
flannel. 

Fomentations.  Application  of  fomentation.  Cut  two  or  three 
thicknesses  of  flannel,  sufficiently  large  to  cover  the  chest.  This  flannel 
is  placed  in  a  crash  towel,  boiling  water  poured  upon  it,  the  ends  of  the 
towel  twisted  in  opposite  directions  to  squeeze  the  water  from  the  flannel. 
The  skin  is  smeared  with  vaseline  or  sweet  oil  and  the  flannels  applied 
with  dry  flannels  outside,  all  of  which  are  kept  in  place  by  a  binder. 
These  are  replaced  as  fast  as  they  become  cool.  Care  must  be  taken  that 
not  enough  hot  water  is  left  in  them  to  drip  down  upon  the  skin  and  burn. 

Counterirritation.  The  application  of  mustard.  One  may  use 
the  mustard  leaf  (charta  sinapis),  although  I  think  the  paste  is  preferable. 
The  mustard  leaf  is  dipped  into  lukewarm  water  to  initiate  the  elabora- 
tion of  the  oil  of  mustard,  a  single  layer  of  gauze  applied  to  its  surface, 
and  two  or  three  to  its  back,  and  applied,  the  mustard  side  toward  the 
chest. 

The  paste  is  made  by  mixing  one  tablespoonful  of  mustard  to  two, 
three  or  four  of  flour  with  cold  water  to  the  consistency  of  a  paste  and 
spreading  it  nicely  on  gauze  or  cheesecloth.  This  is  covered  with  gauze 
and  applied  to  the  chest.  Care  must  be  taken  to  use  cold  or  lukewarm 
water,  as  heat  kills  the  ferment  concerned  in  the  elaboration  of  the  oil. 
The  paste  is  kept  on  ten  or  fifteen  minutes,  then  removed  and  to  the 
skin  is  applied  a  layer  of  sweet  oil  or  vaseline. 

If  the  skin  is  very  sensitive,  the  white  of  an  egg  or  a  little  oil  or  vaseline 
added  to  the  paste  will  make  it  less  irritating. 

The  electric  cautery  or  the  actual  cautery  often  affords  relief.  The 
needle  of  the  cautery  is  held  at  right  angles  to  the  skin  and  lightly  flicked 
across  it  so  that  the  resulting  mark  looks  like  a  pin  scratch.  If  carried 
out  in  this  way  it  will  not  be  painful  and  may  be  repeated  every  other 
day. 

EMPYEMA 

(Pneumococcus  Type) 
(DR.  ALFRED  S.  TAYLOR) 

In  this  type  of  empyema  the  fluid  almost  at  the  start  is  purulent 
and  contains  much  clotted  fibrin.  Also  the  lung  is  adherent  to  parietal 
pleura  all  about  the  periphery  of  the  empyema  cavity.  Therefore  evac- 
uation of  the  pus  by  any  one  of  various  procedures  is  not  likely  to  cause 
sudden  shock  or  circulatory  or  respiratory  embarrassment  because  there 
is  no  flapping  of  the  mediastinum  as  a  result  of  allowing  air  to  enter  the 


188          TREATMENT  OF  ACUTE  INFECTIOUS  DISEASES 

chest.  Therefore  the  problem  is  one  of  evacuating  the  pus  and  healing 
the  cavity  as  rapidly  as  possible.  There  is  a  considerable  range  of  choice 
of  procedure  according  to  the  opinions  of  various  men,  but  the  one  which 
is  straightforward  and  reliable  and  the  best  to  use  under  aU  circumstances 
consists  of  resection  of  a  portion  of  rib  about  7  cm.  long.  The  best  rib  to 
resect  as  a  rule  is  the  8th  at  the  posterior  axillary  border.  This  operation 
can  practically  always  be  done  by  means  of  local  anesthesia.  The  skin 
of  the  chest  is  prepared  as  for  any  operation.  The  patient  is  placed  upon 
the  sound  side  with  the  arm  of  the  diseased  side  hanging  forward  over  the 
edge  of  the  table  or  bed  so  as  to  present  the  rib  to  be  resected  in  a  con- 
venient position  for  the  operator.  One  may  use  Y^  per  cent,  novacaine 
with  1  to  100,000  of  adrenaline  mixed  with  it.  This  should  be  injected 
primarily  into  the  skin  proper  along  the  line  of  incision  and  then  into 
the  subcutaneous  tissues  down  to  the  rib.  It  is  also  helpful  to  remember 
that  the  nerve  supplying  cutaneous  sensation  lies  in  a  groove  along 
the  under  border  of  the  rib.  With  a  little  practice  one  can  readily  insert 
a  needle  beneath  the  edge  of  the  rib  between  the  spine  and  the  incision 
and  inject  some  of  the  novocaine  solution  into  the  nerve  or  its  immediate 
neighborhood.  The  same  procedure  carried  out  on  the  nerve  beneath 
the  7th  rib  will  cause  a  nerve  blocking  of  sensation  in  the  field  of  opera- 
tion. One  might  be  able  to  resect  the  rib  after  just  blocking  the  two 
nerves  alone,  but  the  injection  of  the  skin  and  subcutaneous  tissues 
makes  the  anesthesia  a  little  more  rapid  and  somewhat  more  sure.  In 
all  operations  under  local  anesthesia  it  is  quite  important  to  allow  from 
5  to  10  minutes  to  elapse  after  injecting  the  solution  before  doing  any 
cutting  in  order  to  allow  the  local  anesthetic  to  become  diffused  and 
exert  its  influence.  The  knife  should  be  sharp  and  all  the  instruments  in 
condition  to  do  accurate,  quick  work.  When  anesthesia  has  taken  place 
the  incision  is  made  through  the  skin  over  the  central  line  of  the  8th  rib 
for  a  distance  of  about  7  cm.,  the  middle  being  at  the  posterior  axillary 
border.  This  incision  is  carried  straight  through  all  the  tissues,  including 
the  periosteum.  After  a  certain  amount  of  experience  one  can  make  this 
incision  with  a  single  stroke  of  a  sharp  scalpel.  It  is  better,  however,  for 
one  doing  this  operation  only  occasionally,  to  make  this  incision  layer  by 
layer.  Great  care  must  be  exercised,  however,  to  have  the  incision  follow 
a  vertical  plane  from  the  skin  to  the  rib.  It  must  also  be  remembered 
that  the  axis  of  the  rib  runs  very  sharply  from  below  upward  and  that 
therefore  the  incision  will  have  to  slant  accordingly.  When  the  soft 
tissues  have  been  divided  they  are  retracted  by  sharp  retractors  and  the 
rib  is  exposed  with  its  periosteum  cut  along  its  mid-line.  The  sharp 
periosteal  elevator  is  now  used  to  push  the  periosteum  from  the  middle  of 
the  rib  upward  to  the  upper  border  and  the  lower  half  downward  to  the 


PNEUMONIA  189 

lower  border  of  the  rib.  Care  should  be  exercised  to  separate  the  perios- 
teum as  a  continuous  membrane  instead  of  bruising  and  shredding  it  as 
is  so  often  done.  When  the  upper  border  of  the  rib  has  been  cleared  one 
should  start  at  the  spinal  end  of  the  exposure  and  strip  the  intercostal 
muscle  from  the  upper  border  of  the  rib.  By  starting  posteriorly  and 
working  forward  the  insertion  of  the  external  intercostal  muscles  is  on  a 
slant  that  will  hold  the  periosteal  elevator  against  the  bone.  In  clearing 
the  lower  border  of  the  rib  one  should  begin  anteriorly  and  work  back- 
ward because  the  external  intercostal  muscles  will  again  hold  the  instru- 
ment against  the  bone.  (See  Anatomy.)  When  both  the  upper  and  lower 
borders  of  the  rib  have  been  thus  freed  of  periosteum  and  intercostal 
muscles  the  periosteal  elevator  is  wormed  between  the  periosteum  and 
rib,  starting  at  the  lower  border,  being  careful  to  follow  the  curve  of  the 
groove  beneath  the  lower  edge  of  the  rib  and  then  upward  until  its  edge 
appears  above  the  upper  margin  of  rib.  This  elevator  is  then  pushed 
backward  toward  the  spine  and  forward  as  far  as  the  rib  is  exposed.  This 
separates  the  deeper  layer  of  periosteum  from  the  rib  and  leaves  the 
portion  to  be  resected  entirely  bare.  The  rib  is  now  divided  at  each  end 
by  a  bone  forcep.  Care  should  be  exercised  not  to  crush  the  bone  any 
more  than  is  necessary,  as  damaged  fragments,  which  are  bound  to 
become  bathed  in  pus,  may  keep  suppuration  going  for  some  time  or  may 
even  be  the  source  of  osteomyelitis  of  the  rib.  If  the  deeper  layer  of 
periosteum  is  sensitive  to  a  prick  of  the  knife,  it  may  be  injected  with 
some  of  the  anesthetic  solution.  If,  as  is  usually  the  case,  it  is  anes- 
thetic from  the  nerve  blocking,  a  small  incision,  1  cm.  long,  is  made  in 
its  centre.  This  incision  is  made  purposely  small  to  permit  the  escape 
of  pus  but  to  prevent  it  from  coming  out  too  rapidly.  Too  rapid  evac- 
uation is  apt  to  change  the  pressure  conditions  within  the  thorax  so 
quickly  as  to  cause  some  disturbance  of  cardiac  and  respiratory  action. 
After  the  pus  has  been  permitted  to  escape  somewhat  slowly  the  incision 
is  continued  to  both  ends  of  the  wound.  The  flaps  of  parietal  pleura  are 
then  retracted  sufficiently  to  remove  all  of  the  fibrin  clots  and  pus  either 
with  the  suction  apparatus  or  with  the  finger  or  with  an  ordinary  sponge 
holder.  All  the  manipulations  within  the  abscess  cavity  are  made  with 
the  greatest  gentleness.  Light  should  be  reflected  into  the  cavity  so  that 
the  fibrin  masses  can  be  detached  gently  and  with  certainty.  The  clean 
removal  of  all  these  clots  and  of  the  liquid  pus  will  shorten  the  convales- 
cence materially.  The  simplest  form  of  drainage  consists  of  two  pieces 
of  flexible  rubber  tubing  about  1  cm.  in  diameter  externally.  These  tubes 
should  be  long  enough  to  project  slightly  into  the  pleura!  cavity  and 
allow  for  their  other  ends  to  be  joined  by  a  transfixing  safety  pin.  A 
narrow  cotton  tape  is  fastened  to  the  pin  and  tied  around  the  chest  to 


190  TREATMENT  OF  ACUTE  INFECTIOUS  DISEASES 

prevent  the  tubes  from  falling  into  the  cavity.  Most  of  the  wound  is 
sutured  until  there  is  just  room  for  two  tubes  to  emerge.  Sterile  dress- 
ings are  applied  and  held  on  usually  by  a  wide  bandage  which  is  pinned 
not  too  tightly  about  the  chest.  The  after-treatment  consists  of  chang- 
ing the  dressings  as  often  as  necessary  to  keep  the  patient  from  getting 
too  wet.  Every  day  or  every  second  day  the  tubes  are  removed,  washed 
clean  and  sterilized.  The  skin  about  the  wound  is  kept  clean  and  the 
tubes  are  replaced.  Meanwhile  as  soon  as  the  patient's  general  condition 
permits  he  is  started  on  blowing  exercises,  i.  e.,  Wolff's  bottles.  As  soon 
as  his  general  condition  permits  he  is  allowed  to  sit  up  and  get  about. 
When  the  discharge  has  almost  disappeared  the  tubes  can  be  removed. 
This  usually  occurs  in  10  days  or  two  weeks.  This  is  the  simplest  proce- 
dure and  in  most  ways  answers  the  purpose  everywhere.  In  well-con- 
ducted hospitals,  one  may  use  plain  thoracotomy  between  the  ribs,  then 
force  a  large  rubber  drain  tube  into  the  cavity  so  that  it  fits  air  tight  into 
the  incision,  or  one  may  use  any  one  of  the  various  methods  for  getting 
vacuum  drainage  of  the  empyema  cavity.  These  methods  certainly 
shorten  the  time  of  convalescence  and  keep  the  patient  much  drier 
between  dressings,  but  they  are  somewhat  more  fussy  and  require  more 
constant  skilled  attention.  In  the  same  way  the  use  of  Dakin's  solution 
is  an  advantage  in  well-conducted  hospitals  where  the  technique  can  be 
properly  carried  out,  but  as  a  general  rule  these  cases  will  do  very  well 
when  treated  in  the  way  described. 

Pneumococcus  Endocarditis  commonly  occurs  as  a  late  com- 
plication and  whenever  after  an  apparent  crisis  the  temperature  rises 
again  it  should  be  thought  of  together  with  empyema  as  the  most  prob- 
able explanation;  or  crisis  failing  and  the  temperature  being  prolonged 
and  more  particularly  if  it  is  of  an  irregular  type  the  same  condition 
should  be  suspected.  There  may  or  may  not  be  chills  and  sweat.  Such 
an  endocarditis  constitutes  an  acute  malignant  endocarditis  with  the 
usual  sequence  of  events — septicemia,  septic  infarcts  and  death. 

The  physical  signs  are  those  of  valvular  inefficiency  and  stenosis. 

The  treatment  is  that  of  a  septicemia.    (See  Chapter  XLV.) 

Thrombosis  is  a  rare  complication  occurring  usually  in  the  fe- 
moral veins.  The  treatment  is  that  of  rest  by  fixation  of  the  limb  and 
application  of  thick  layers  of  non-absorbent  cotton  or  wet  dressings 
such  as  aluminum  acetate. 

Embolism  with  thrombosis  of  the  arteries  is  another  rare  ac- 
cident. A  dry  gangrene  will  ensue  and  if  occurring  in  a  limb  may  neces- 
sitate amputation.  One  such  case  occurring  on  our  service  at  Bellevue 
in  an  old  man  was  followed  by  an  amputation  of  the  thigh  followed  by 
good  results. 


PNEUMONIA  191 

Meningitis.  Fortunately  this  is  not  a  common  occurrence.  On 
the  other  hand,  it  may  not  be  considered  as  a  rarity.  The  issue  is  always 
a  fatal  one.  The  treatment  aims  at  relieving  the  symptoms;  repeated 
lumbar  puncture  is  a  valuable  contributary  to  other  procedures.  (For 
details  see  Cerebro-Spinal  Meningitis,  Chap.  XXV.) 

Parotitis  is  another  of  the  relatively  uncommon  complications 
and  is  frequently  associated  with  endocarditis.  There  is  no  doubt 
that  lack  of  attention  to  oral  hygiene  is  largely  the  cause.  (For  treatment 
see  Mumps.  Chap.  XXIII.) 

Arthritis  may  be  an  early  manifestation  or  occur  at  any  time 
during  the  course  or  follow  upon  the  pneumonia.  It  may  be  of  the  nature 
of  a  toxic  arthritis  and  yield  to  such  measures  as  are  detailed  under 
Acute  Rheumatic  Fever  (Chap.  Ill)  or  it  may  be  suppurative  and 
demand  surgical  interference. 

Peritonitis  is  a  rare  complication  and  occurs  usually  in  the 
severer  cases.  It  is  sometimes  in  the  upper  peritoneum  and  a  direct 
extension  through  the  diaphragm. 

Jaundice  is  not  an  uncommon  occurrence  in  pneumonia.  It 
is  usually  taken  to  signify  an  intense  infection  and  may  be  due  to  the 
parenchymatrous  degeneration  of  the  liver  with  obstruction  of  the 
biliary  duct.  The  prognosis  is  correspondingly  serious.  When,  as  not 
infrequently  happens,  the  earliest  signs  of  pneumonia  refer  to  the  in- 
volvement of  the  diaphragmatic  pleura  or  the  lower  portion  of  the  costal 
pleura,  pain  is  referred  to  the  region  of  the  gall  bladder  and  sensitiveness 
of  the  skin  and  muscles  over  that  structure,  leads  to  the  diagnosis  of  a 
primary  cholecystitis.  It  is  the  knowledge  of  this  fact  with  twenty-four 
to  thirty-six  hours  of  watchful  waiting  that  saves  one  from  an  embar- 
rassing diagnosis,  especially  if  surgical  procedure  is  immediately  in- 
stituted. The  jaundice  per  se  requires  no  treatment. 

Abdominal  Pain. — The  errors  of  diagnosis  incident  upon  abdom- 
inal pain  referred  from  diaphragmatic  pleurisy  have  been  discussed  under 
that  subject  and  in  the  preceding  paragraph.  One  should  merely  keep 
in  mind  in  the  pneumonia  season  that  acute  onsets,  with  high  fever  and 
with  pain  thought  to  be  due  to  involvement  of  gall  bladder,  appendix, 
pancreas  or  to  a  gastric  ulcer  may  be  due  to  the  pneumonic  process. 

Relapses  may  occur  on  the  ninth  to  eleventh  day  with  return 
of  fever  and  physical  signs.  It  must  be  remembered  that  a  return  of  fever 
shortly  after  defervescence  is  probably  due  to  an  empyema  or  possibly 
an  endocarditis. 

The  treatment  is  the  same  as  for  the  original  attack. 


192  TREATMENT  OF  ACUTE  INFECTIOUS  DISEASES 

CONVALESCENCE 

The  period  of  convalescence  appeals  to  the  good  judgment  of  the 
physician  quite  as  much  as  any  other  period  of  the  illness;  for  the  failure 
to  appreciate  the  possibilities  of  convalescence  may  result  in  immediate 
disaster  or  more  remote  consequences  unfortunate  for  the  patient.  It 
must  be  remembered  that  after  the  defervescence  resolution  must  occur, 
and  that  the  patient  should  not  be  allowed  to  sit  up  or  raise  himself  up  in 
bed  until  the  resolution  is  complete,  since  it  is  during  this  period  that 
pulmonary  embolism  may  occur,  the  result  of  which  is  often  immediate 
death,  or,  if  the  toxemia  has  been  profound  and  the  myocardium  much 
weakened,  cardiac  dilatation  may  ensue. 

If  the  course  of  the  disease  has  not  been  peculiarly  severe  one  may 
say  in  a  general  way  that  a  week  after  resolution  has  occurred  the  patient 
may  be  allowed  out  of  bed ;  but  if  the  toxemia  has  been  severe  and  the 
condition  of  the  circulation  during  the  disease  has  been  a  source  of 
anxiety,  possible  weakening  of  the  myocardium  must  be  kept  in  mind 
and  the  patient  be  kept  in  bed  for  a  longer  period.  He  should  be  allowed 
to  be  bolstered  up  in  bed  at  first,  then  allowed  to  get  out  of  bed,  then 
allowed  to  get  about;  but  each  increment  of  freedom  from  restraint 
should  be  granted  only  when  the  heart  shows  no  irritability  on  the  occa- 
sion of  increased  effort. 

Complications  such  as  empyema,  abscess  of  the  lung,  gangrene  of 
the  lung,  and  so  forth,  of  course,  prolong  the  convalescence. 

Care  must  be  given  to  the  dietary,  sufficiency  of  food  given  and  the 
value  of  fresh  air  to  the  convalescent  be  fully  appreciated. 

It  is  often  most  difficult  to  restrain  the  patient  from  returning  to 
his  work,  particularly  where  much  is  dependent  upon  his  effort.  How 
soon  the  patient  shall  be  allowed  so  to  do,  rests  entirely  upon  the  good 
judgment  of  the  physician  and  no  rules  can  be  laid  down  for  him  in  this 
matter,  except  that  a  restoration  of  strength  and  weight  and  well-being 
in  the  patient  are  the  criteria. 

If  there  has  been  much  pleurisy  the  convalescence  is  likely  to  be 
prolonged  and  pulmonary  exercises,  deep  breathing,  or  blowing  into 
bottles  (see  Pleurisy,  Chap.  VIII)  are  necessary  for  the  proper  expansion 
of  the  lungs. 

Prophylaxis.  It  must  be  remembered  that  the  infecting  agent 
finds  its  entrance  into  the  body  through  the  air  passages. 

An  examination  of  the  throat  and  nasal  passages  of  healthy  individuals 
has  shown  that  a  very  goodly  per  cent,  of  such  are  carriers  of  the  pneu- 
mococcus.  It  is  obvious,  then,  that  any  abnormalities  of  the  air  passages 
favor  a  lodgment  of  the  organism  and  the  exercise  of  their  pathological 


PNEUMONIA  193 

activities.  Oral  hygiene  then  becomes  of  importance,  proper  dental  care 
of  the  teeth,  the  use  of  a  tooth-brush,  attention  to  or  removal  of  hyper- 
trophied  tonsils,  adenoids  or  other  diseased  lymphoid  tissue,  proper 
treatment  of  deviated  septum,  hypertrophied  turbinates  and  other 
abnormalities  of  the  nasal  passages. 

It  must  be  remembered,  too,  that  any  lowering  of  the  resistance  of  the 
body  at  large  favors  infection  so  that  attention  to  diet,  exercise,  clean- 
liness of  the  body  on  the  one  hand  and  avoidance  of  undue  fatigue, 
mental  worry,  dissipation,  alcoholism,  exposures  to  cold,  failure  to 
change  cold  wet  clothing,  are  all  to  be  avoided. 

It  must  be  remembered,  too,  that  the  lessened  resistance  entailed 
by  another  illness  favors  pneumonia  as  a  complication. 

There  is  no  question  that  a  large  percentage  of  individuals  carry 
pneumococcus  in  the  upper  air  passages.  The  organism  increases  in 
virulejicy  and  in  infectivity  in  those  people  who  are  suffering  from  any 
expression  of  infection,  such  as  common  colds,  sore  throats,  bronchitis 
and  pneumonia.  Hence,  people  in  health  should  avoid  unnecessary  and 
immediate  contact  with  the  sick,  avoid  kissing,  exposure  to  coughs,  use 
great  care  in  handling  the  sputum  of  patients  ill  with  pneumonia  or  with 
bronchitis  or  common  colds,  avoid  crowded  places  during  periods  of 
epidemics  of  colds.  It  must  be  remembered,  too,  that  those  who 
have  suffered  from  a  pneumonia  once  are  more  prone  to  repeated 
attacks. 

Prophylaxis,  too,  is  a  function  of  the  State  and  pertains  to  Boards  of 
Health,  Street  Cleaning  Departments,  Building  Departments  and  all 
such  bodies  as  have  to  do  directly  or  indirectly  with  the  health  of  the 
public  at  large,  while  a  dissemination  of  proper  knowledge  regarding 
disease  is  the  duty  of  Boards  of  Education,  Health  Officers,  and  Medical 
Organizations. 

Prophylactic  Use  of  Pneumococcus  Vaccines.  Many  observa- 
tions on  the  value  of  piophylactic  vaccination  with  pneumococcus  were 
made  in  the  Army,  but  the  measure  has  not  won  its  way  into  civil  prac- 
tice as  yet  to  anything  like  the  extent  of  prophylactic  typhoid  vaccina- 
tion; and,  indeed,  the  efficiency  of  the  one  as  contrasted  with  the  other 
has  not  up  to  the  present  time  warranted  it.  However,  such  figures  as 
have  been  published  from  the  various  camps  where  anti-pneumococcus 
vaccine  was  used  encourages  one  to  the  belief  that  it  will  be  extensively 
used  in  civil  practice.  A  personal  communication  from  Cecil,  whose 
experience  in  this  practice  has  been  very  large,  describes  the  procedure 
as  follows:  The  vaccine  is  made  from  Types  I,  II,  and  III  in  equal  parts, 
suspended  in  saline  solution.  The  first  dose  contains  a  billion  of  each, 
second  dose  two  billion  of  each,  third  and  fourth  doses  two  and  three 


194  TREATMENT  OF  ACUTE  INFECTIOUS  DISEASES 

billion  of  each  of  Types  I  and  II  and  one  and  a  half  of  Type  III.    The 
intervals  are  5-7  days. 

The  reactions  are  much  the  same  as  after  administrations  of  typhoid 
vaccine.  (See  Chap.  XIV.)  But  the  formation  of  sterile  abscesses  at  the 
site  of  injection  was  not  an  uncommon  happening  and  of  course  not  a 
desirable  one.  This  disagreeable  sequel  was  quite  avoided  'by  the  use 
of  lipovaccines  although  there  is  reason  to  believe  that  the  formation  of 
antibodies  is  not  so  active  from  the  latter  as  from  saline  vaccines.  The 
lipovaccines  consist  of  an  emulsion  of  centrifugated  and  dried  bacterial 
bodies  in  cotton  seed  oil.  With  lipovaccines  not  only  are  the  possibilities 
of  sterile  abscesses  quite  eliminated,  but  general  reactions  are  much 
diminished  and  so  much  larger  doses  may  be  given  as  to  make  a  single 
vaccination  sufficient.  In  this  case  it  is  customary  to  give  10  billion  of 
each  of  the  bacteria.  Dr.  Cecil's  figures  show — 

INCIDENCE  OF  PNEUMONIA  AMONG  THE  VACCINATED  TROOPS,  FEBRUARY  4  TO  l 
APRIL  15,  1918  AT  CAMP  UPTON 

Average  strength  of  command,  Feb.  4  to  April  15,  1918 32,000 

No.  of  troops  vaccinated  against  pneumonia 12.519  (40%) 

"     "  unvaccinated  men  (average) 19.481  (60%) 

Total  No.  of  Type  I — Pneumonias  among  the  unvaccinated  troops  Feb.  26 

to  Apr.  15 10 

"    "      "   II   and   III   pneumonias   among  the  unvaccinated 

troops 16 

"       "    "      "   I,  II,  III  and  IV  pneumonias  among  the  unvaccinated 

troops 59 

"       "    "     Streptococcus    pneumonias    among   the   unvaccinated 

troops 106 

"       "    "     Pneumonias  among  the  unvaccinated  troops 173 

Incidence  of   pneumonia  among  the  vaccinated  troops,  Feb.  4  to  Apr.  15 

Pneumococcus  Type  I  (developed  24  hrs.  after  first  injection) 1 

Pneumococcus  Type  IV  (3  cases  receiving  only  one  injection) 9 

Streptococcus  hemoliticus 6 

viridans 1 

Total  number  of  pneumonias  among  the  vaccinated  troops 17 

As  pneumonia  is  responsible  for  more  deaths  than  any  other  infectious 
disease  with  which  we  are  acquainted,  ranking  even  tuberculosis,  one 
can  easily  understand  the  wonderful  benefit  that  would  ensue  if  these 
figures  were  sustained  by  further  observation. 

SUMMARY 
Rest. 

Rest  in  bed. 

Do  not  allow  patient  to  turn  himself  if  very  ill. 

1  Journal  of  Experimental  Medicine,  July  1,  1918. 


PNEUMONIA 


195 


Exclude  visitors. 

Permit  no  subjects  of  mental  concern  to  be  brought  to  the  patient. 

Bed. 

Half  or  three-quarter  bed. 

Hospital  type  preferred. 

Woven  wire  springs,  firm  mattress. 

Bed  clothing,  sheets  and  light  weight  blankets. 

(For  technique  of  bed-making  see  text.) 

In  convalescence  bed  rests  are  used.  The  constant  tendency  to  slide 
indicates  some  support,  rolled  blankets  under  the  knees  or  foot- 
rests;  all  unsatisfactory. 

A  bed  of  the  type  of  the  Gatch  bed  is  the  best.     (See  text.) 

Room. 

Chosen  for  light  and  air. 
Stripped  of  all  unnecessary  furniture. 
Access  to  porch  or  verandah  desirable. 
Temperature  about  65°  F. 

Specific  treatment. 
Determine  the  organism. 

Culture  blood;  likely  to  get  results  in  early  hours. 
Culture  sputum. 
When  the  organism  is  a  pneumococcus,  proceed  to  type  the  pneumococ- 

cus. 
The  determination  of  the  organism  and  typing  should  be  done  at  the 

earliest  possible  moment. 
Technique  of  typing.     (See  text.) 
Typing  may  be  done  from  the  urine.    (For  technique,  see  text.) 

Administration  of  serum. 

At  the  earliest  possible  moment  after  typing  determines  Type  I 
pneumococcus,  give  serum. 

Shall  serum  be  administered  when  typing  is  not  possible?  (For  dis- 
cussion, see  text.) 

Determine  presence  or  absence  of  Sensitizalion. 

Always  enquire  about  asthmatic  attacks,  or  previous  serum  adminis- 
tration of  any  kind.  These  patients  are  likely  to  be  sensitized. 

Sensitization  test.     (See  text.) 

If  the  patient  is  proven  to  be  sensitized,  before  serum  is  given  in  full 
dosage  he  must  be  desensitized. 

Desensitization.     (For  details,  see  text.) 

Note  Besredka's  method,  intravenous  from  the  start  and  the 
Rockefeller  Institute  method,  beginning  with  subcutaneous 
doses. 

Giving  of  Serum. 

Assembling  of  apparatus.     (See  text.) 
Sterilizing  apparatus.     (See  text.) 
Preparation  of  serum.     (See  text.) 


196  TREATMENT  OF  ACUTE  INFECTIOUS  DISEASES 

Preparation  of  patient  and  operator.     (See  text.) 
Method  of  injection.     (See  text.) 

Reactions. 

1.  Non-specific   serum   or   thermal   reaction — much   like   salvarsan 
reaction.    (For  symptoms,  see  text.) 

If  it  occurs  during  the  serum  administration,  discontinue  for  an 

hour  or  two,  then  resume  more  slowly. 
To  ameliorate  symptoms: 

Adrenalin  (epinephrin)  1-1000,  m.  vii  (0.5  c.c.)  intramuscularly. 

Atropine  sulphate  gr.  1/100  (0.0006  Gm.)  intramuscularly. 

2.  Serum  sickness  or  serum  disease  7-14  days  after  administration. 
(For  symptoms,  see  text.) 

Relief  of  urticaria. 

Bathing  in  solutions  of  bicarbonate  of  soda  of  varying  strengths. 

Apply  l%-2%  aqueous  solutions  of  phenol  (carbolic  acid)  or 

5%-10%  solutions  of  phenol  in  olive  oil  or  vaseline  (liquid 
petrolatum) . 

Adrenalin  (epinephrin)  1-1000,  Y^  to  1  c.c.  (m.  vii-xv)  intra- 
muscularly. 

3.  Anaphylactic  reaction. 

Occurs  during  or  immediately  after  administration. 

(For  symptoms,  see  text.) 

Adrenalin  (epinephrin)  1-1000,  1  c.c.  (m.  xv)  intramuscularly  at 

once. 
If  pulse  is  soft  and  blood  pressure  low,  strophanthin,  J/£  mg.  (gr. 

1/120)  intravenously  or 

Digitalis  intravenously  in  some  form  in  doses  equal  to  3  to  5 
grains  of  the  leaf,  e.  g.,  tincture  (m.  xxx-1  (2.-3.3S  c.c.)  diluted 
with  saline  2  or  3  times  or  digitoxin  gr.  1/100-1/60  (0.0006- 
0.001  mg.)  in  m.  x  (0.66  c.c.)  alcohol  diluted  twice  with  normal 
saline  solution  or, 

Properly  assayed  commercial  solutions  in  equivalent  doses. 

Apply  hot  cloths  to  the  abdomen;  i.  e.,  treat  as  a  shock. 

Asthma  of  an  intense  type  often  accompanies  it. 

Adrenalin  (epinephrin)  m.  xv-xxx  (1-2  c.c.)  intramuscularly. 

Atropine  sulphate  gr.  1/50  (0.0012  Gm.)  intramuscularly. 

Morphine  sulphate  gr.  1/8-1/4  (0.008-0.015  Gm.). 

In  unyielding  cases  air  may  be  expressed  rhythmically  from 
chest  by  force,  i.  e.,  compressing  the  chest  with  the  operator's 
encircling  arms. 

Dosage  of  serum.  60-100  c.c. ;  the  larger  in  toxic  cases.  There  is  no  toxic 
dose,  the  amount  is  limited  only  by  the  supply  at  hand  and  demand  in 
the  individual  case.  Late  cases  demand  larger  doses.  Larger  and 
larger  doses  are  needed  as  the  disease  advances,  to  get  equivalent 
results. 

Frequency  of  dosage. 

Eight  hours  or  less  in  severe  cases.     In  cases  showing  improvement 
the  physician's  judgment  must  determine  intervals. 


PNEUMONIA  197 

Care  of  body. 

Sponge  baths  for  cleanliness. 
Mouth. 

Use  mild  antiseptic  solution  2  to  4  per  cent,  of  boric  acid. 

Yito^A  strength  of  Dobell's  solution. 
Teeth. 

Keep  interstices  free  from  food,  use  swabs  of  absorbent  cotton  or 

wooden  toothpicks  in  above  solution. 
Tongue. 

For  coated  tongue  and  sordes  on  lips  and  teeth  use  }/£  strength  of 
peroxide  of  hydrogen  to  soften.  Scrape  with  edge  of  whalebone 
and  then  use  above  solution. 

For  very  dry  mouth,  equal  parts  of  albolene  and  2  per  cent,  boric 

acid  solution,  flavored  with  lemon  juice. 
Fetid  breath  and  marked  stomatitis. 

Phenol,  watery  solution  1-20. 

Glycerin aa  $i  (30  c.c.). 

Boric  acid  saturated  watery  solution. .  gviii         (240  c.c.). 
Naso-pharynx. 

Remove  collections  with  cotton  swab  on  long  applicators  saturated 
with  above  solution. 

Use  sprays  of  boric  acid  or  DobelPs  solution. 
Nose. 

Soften  dried  secretions  with  sweet  oil. 

Cleanse  with  cotton  swab  on  toothpicks,  using  above  solution. 

Spray,  using  above  solutions. 

Avoid  irrigations. 
Fissures  and  herpetic  eruptions. 

Use  above  solutions  and  anoint  with  oil  or  vaseline. 
Eyes. 

Cleanse  with  2  per  cent,  boric  acid  solutions. 
Genitals. 

Cleanse  with  boric  acid  and  Dobell's  solutions. 
To  excoriations. 

Apply  \]/2  per  cent,  to  2  per  cent,  phenol  solution. 

Apply  and  keep  dry  with  dusting  powders. 

Diet. 

Do  not  force  food  during  the  early  hours. 

Do  not  force  food  during   the  high  temperature  of  a  lobar  pneu- 
monia. 

The  longer  course  of  a  broncho-pneumonia  indicates  food  of  a  higher 
caloric  content. 

Milk. 

Each  ounce  equals  20  calories. 

Gravity  cream  16  per  cent,  each  ounce  equals  50  calories. 
Milk  sugar  each  ounce  equals  120  calories. 

One  may  add  1  ounce  of  cream  and  J^  ounce  of  milk  sugar  to  each 
glass  of  milk,  thus  increasing  the  calories  about  100. 


198  TREATMENT  OF  ACUTE  INFECTIOUS  DISEASES 

Cereals. 

Oatmeal. 

Hominy. 

Farina.  « 

Rice. 

An  ordinary  serving  of  which,  of  3  to  5  ounces,  equals  100  calories. 

In  addition,  eggs,  cup  custard,  broths  made  of  cereals  'and  milk, 

bread  and  butter. 
Milk  preparations  such  as, 

Matzoon. 

Koumys. 

Zoolak. 

Buttermilk. 

Curds  and  whey. 
If  the  patient  much  desires  it  meat  soups  such  as, 

Mutton  broth. 

Chicken  broth  to  which  may  be  added  cereals  or  rice  to  add  to 
the  caloric  value. 

Or  cream  soups. 
Desserts. 

Tapioca  pudding. 

Gelatin. 

Ice  cream. 

Prune  whip. 
Meats. 

Brains. 

Scraped  beef. 

Chicken  livers. 

Fish  roe. 
Potatoes. 

Sweet  and  Irish. 
Summary  of  diet. 

Early  days,  small  amounts  of  milk,  large  amounts  of  water,  and 
milk  better  diluted  with  plain  water,  alkaline  water  or  cereal 
water. 

Increase  food  gradually. 

In  prolonged  pneumonias,  broncho-pneumonias,  unresolved  pneu- 
monias, complicated  pneumonias,  increase  to  a  high  calorie 
diet. 

Food  may  be  given  at  two  or  three  hour  intervals. 
Drinks. 

Give  water  abundantly. 

To  stuporous  or  delirious  patients  offer  water  every  hour  or  two. 
Fruit  juices. 

Lemonade,  orangeade,  grape  juice,  imperial  drink  may  be  given 
freely. 

Care  of  bowels. 

When  first  seen. 

Calomel,  gr.  %  (0.015  Gm.)  every  J^  hour  for  6  or  8  doses. 
In  children  gr.  1/10  (0.006  Gm.)  every  10  minutes  for  10  doses. 


PNEUMONIA  199 

In  the  adult  followed  in  three  or  four  hours  by  salts,  Rochelle  or 
Epsom,  Yi  ounce  (15  Gm.)  in  J^  to  %  of  a  glass  of  water. 

In  children  follow  in  two  to  three  hours  by  4  to  8  ounces  (120- 
240  c.c.)  of  Liq.  Magnesii  Citratis,  or  Y^  to  1  ounce  (15-30  c.c.) 
of  milk  of  magnesia. 

Or  salts  alone  may  be  used,  Rochelle,  Epsom  or  Glauber's  J£  to  1 
ounce  in  adults  (20-30  c.c.). 

Or  milk  of  magnesia  ^  to  1  ounce  (15-30  c.c.)  in  children. 

Later  enemata  of  plain  water  or  soap-suds. 

Liquid  petrolatum  (mineral  oil)  in  doses  of  one  or  more  table- 
spoonfuls. 

Tympanites. 

Suspect  the  fat  of  milk,  or  the  milk  sugar. 
Cut  them  down  or  eliminate. 
Plain  water  or  soap-suds  enemata,  or  add  oil  of  turpentine  %  oz.  to  1 

oz.  (15-30  c.c.)  to  soap-suds  enema. 
(For  technique  see  text.) 
Peppermint  enema — 2  teaspoonfuls  of  essence  of  peppermint  (spiritus 

menthae  piperitae)  to  2  quarts  of  warm  saline  solutions. 
Asafcetida  enema — 3ss.  (2  c.c.)  of  tincture  of  asafoetida  to  2  quarts 

(2  litres)  of  normal  saline  or  tap  water. 
MUk  and  molasses  enema.    A  cupful  of  each  (200-250  c.c.).    Warm 

the  molasses  and  add  warm  milk.    Have  temperature  a  little  above 

body  temperature.    Give  with  funnel  and  tube. 
Rectal  tubes. 

Glycerin  rectal  injections  5i  to  3ii  (30-60  c.c.). 
Strychnine  for  tonic  effect  gr.  1  /30  (0.002  Gm.)  three  times  a  day  or 

four  times  a  day. 
Pituitrin  or  pituitary  extract. 

1  c.c.  (m.  xv)  hypodermically  is  the  usual  dose. 
Murphy  drip.    (See  text.) 

Open  air  treatment.    (See  text.) 

Bed. 
Woven  wire  spring;  over  this 

1.  Large  blanket;  over  this 

2.  Rubber  sheeting  or  paper;  over  this 

3.  Mattress,  sheets  and  blankets. 
Fold  1  and  2  over  3  like  an  envelope. 

Patient. 

Flannel  undersuit. 

Stockings. 

Hood. 

Low  pillow. 

Pillows  for  shelter  like  an  inverted  V. 

Hot  water  bottle  to  feet. 


200  TREATMENT  OF  ACUTE  INFECTIOUS  DISEASES 

Screens  for  high  winds. 

Must  not  be  left  alone. 

Nurses  and  attendants  dressed  for  out  of  doors. 

For  toilet,  use  of  bed-pan,  examination,  draw  into  room  at  65°  F 

to  70°  F. 
For  open-air  treatment  may  use  verandah,  porch,  fire-escape,  roof, 

room  with  windows  out  and  screened  with  cheese  cloth. 


Hydrotheraphy.     (See  text.) 

Chest  compresses.   Technique,  see  text. 


Symptomatic  treatment. 
Fever. 
Let  alone  unless  temperature  is  above  105°  F.  or  sustained  at 

about  104°  F. 

Brand  bath.    (See  Typhoid  Fever,  Chap.  XIV.) 
Take  patient  out  at  102°  F.  to  102.5°  F. 
Slush. 
Pack. 

Sheet  bath.     (For  technique,  see  text.) 
Sponges. 
Rectal  injections  of  cold  water. 

Drugs. 

Only  when  cold  water  cannot  be  used. 
Phenacetin  gr.  v 
or 


Antipyrin  gr.  iv 

or 
Acetanilid  gr.  ii 


Every  2  hours,  but  cautiously  watch  pulse. 


Cough. 

Due  to  pleurisy. 

Strapping  chest.    (For  technique  see  text.) 

Mustard  leaf  or  paste.    (For  technique  see  text.) 

Poultice.    (For  technique  see  text.) 

Fomentations.     (For  technique  see  text.) 

Ice  bag.    (For  technique  see  text.) 

Codeine  phosphate  or  sulphate,  gr.  1/8  togr.  1/4  (0.008-0.015  Gm.) 
every  two  hours. 

Morphine  sulphate  (in  very  severe)  gr.  1/16  to  gr.  1/8  (0.004-0.008 

Gm.)  at  4  hour  intervals. 
Due  to  bronchitis. 

Its  purposefulness.    (See  text.) 

Mustard  paste  or  leaf. 

Dry  cupping.    (For  technique  see  text.) 

Wet  cupping.    (For  technique  see  text.) 

(See  also  Bronchitis,  Chap.  VIII.) 


PNEUMONIA  201 


Inhalations. 

In  croup  kettle  or  similar  device.    (See  text.) 
Steam,  plain  or  medicated  with, 
Compound  tincture  of  benzoin, 
or 


Oil  of  pine, 

or 
Oil  of  eucalyptus 


3i  to  3ii  (8-15  c.c.). 


9 

Mentholis 

Camphorae  ...................................  aa  5  i  (4) 

Tr.  Benzoini  Co.  q.  s.  ad  ..........................  5ii          (60) 

S.    Use  a  teaspoonful  to  a  pitcher  of  hot  water  as  an  inhalation. 


Alcohol. 

Chloroform. 

Creosote,  equal  parts. 

M.  et  S.  gtt.  x  on  sponge  or  inhaler.    (See  text.) 

Drugs. 

Codeine  phosphate  or  sulphate  1 

Morphine  sulphate  [  See  cough  of  pleurisy  above. 

Heroine  hydrochloride 
Heroine  may  be  combined  witn  terpin  hydrate  as  Elixir  Terpini 

Hydratis  cum  Heroinai  (N.  F.).    Dose  3i-ii  (4-8  c.c.)  in  water 

every  3  hours. 
Expectorants.    (Too  much  used,  rarely  indicated.) 

9 

Ammonii  Chloridi  .............................  gr.  xlv         3.  00 

Syrupi  Tolutani  ..............................  gss.  15.00 

Aquae  Destillatee  q.  s.  ad  ......................  5ii  60.00 

M.  et  S.    One  teaspoonful  in  water  every  three  hours. 

Pain. 
Pleurisy. 

(See  measures  for  cough  of  pleurisy  above.) 

Toxemia. 

Rest. 

Diet. 

Air. 

Care  of  skin. 

Care  of  bowels. 

Delirium. 

Watch  patient  continuously. 
Open-air  treatment  or 
Hydrotherapy. 


202  TREATMENT  OF  ACUTE  INFECTIOUS  DISEASES 

Ice  bag  to  head. 

Lumbar  puncture.     (For  discussion,  see  text.     For  technique,  see 
Cerebro-spinal  Meningitis,  Chap.  XXV.) 

Drugs. 

Codeine  phosphate  gr.  1/8  to  gr.  1/4  (0.008-0.015  Gm.)  .hypodermic- 
ally.    Morphine  sulphate  (if  severe),  gr.  1/16  to  gr.  1/12  (0.004-0.005 

Gm.)  hypodermically. 
Hyoscine  hydrobromide  (less  reliable  and  less  safe),  gr.  1/200  to  gr. 

1/150  (0.0003-0.00045  Gm.)  hypodermically. 

Sleeplessness  and  restlessness. 
Bromides. 

Potassium  bromides  or  mixed  bromides,  gr.  xxx  (2  Gm.)  at  night 

or  gr.  xv  (1  Gm.)  three  times  a  day. 
Trional. 

gr.  xv  (1  Gm.)  in  wine,  whiskey  or  warm  drink  in  early  evening. 

Repeat  in  two  hours  if  needed. 

May  begin  early  in  day  and  give  gr.  ii  (0.125  Gm.)  doses  at  2  hour 
intervals  and  if  there  is  no  disposition  to  sleep  in  evening  rein- 
force with  gr.  x  (0.66  Gm.). 

Sometimes  gr.  v  (0.33  Gm.)  after  last  meal  is  effectual. 
Chloralamid. 

gr.  xx  to  gr.  xxx  (1.30-2  Gm.)  in  wine,  whiskey  or  cold  drink  in 
early  evening. 

Repeat  in  two  hours  if  needed. 
Barbital  (Veronal)  gr.  v-vii  ss.  (0.33-0.50  Gm.)  in  capsule,  cachet  or 

dry  on  tongue,  to   be   washed    down  with   water.     Disagreeable 

after  effects  are  not  rare. 
Barbital  sodium  (medinal)  a  more  soluble  modification  of  barbital, 

gr.  v-vii  ss.  (0.33-0.50  Gm.)  by  mouth.    Has  been  used  by  rectum 

and  hypodermically.    I  have  had  no  experience  with  the  drug  by 

either  the  rectal  or  subcutaneous  route. 
Adalin,  gr.  v-xv  (0.33-1  Gm.)  in  capsule,  tablets  or  powder  —  not 

soluble  in  water;  is  in  alcohol. 
Paraldehyde  (in  alcoholics)  5ii  to  5iv  (8-15  c.c.)  in  whiskey,  brandy 

or  water  (1  in  8). 

doses  as  in  delirium.    (See  above.) 


Headache. 

Ice  cap  or  cold  coil. 

Bromides,  gr.  xv  to  gr.  xx  (1  to  1.30  Gm.)  in  water. 

Morphine  sulphate  (severe)  smallest  doses  effectual. 

Codeine  phosphate  or  sulphate  gr.   1/8  (0.008  Gm.)  by  mouth  or 

hypodermically. 

Acetyl  salicylic  acid  (aspirin)  gr.  v-x  (0.33^0.66  Gm.)  in  capsules. 
May  be  due  to  meningismus  or  serous  meningitis  and  indicate  lumbar 

puncture.    (For  technique,  see  Cerebro-spinal  Meningitis,  Chap. 

XXV.) 


PNEUMONIA  203 

Circulation. 

It  is  well  to  digitalize  the  heart  in  any  case  of  pneumonia  unless  it  is 

obviously  a  light  attack. 

Be  sure  that  the  digitalis  comes  from  reliable  sources  and  if  a  product 
that  has  been  physiologically  assayed  is  obtainable  it  is  to  be  pre- 
ferred. 

Preparations  should  be  fresh. 

Eggleston's  rule  for  digitalization  is  about  m.  ii  (0.125  c.c.)  of  reliable 
tincture  per  pound  of  patient.    This  is  roughly  300  minims  for 
an  adult  (150  pounds). 
It  should  be  given  in  24  to  36  hours. 
First  dose  100-150  minims  (6-10  c.c.). 
Second  dose,  75  minims  (5  c.c.)  4-6  hours  after  first. 
The  remainder  of  the  dose  at  4-6  hour  intervals,  so  divided  as  to 

get  the  whole  amount  in,  in  24  to  36  hours. 
The  urgency  of  the  case  determines  the  larger  or  smaller  doses  and 

the  shorter  or  longer  intervals. 
Such  rules  are  not  to  be  slavishly  followed. 
In  very  urgent  cases  the  whole  300  minims  may  be  administered  in 

12-16  hours. 

Clinical  results  will  follow  in  36  hours  or  24  or  12  hours  if  pushed. 
Many  cases  need  50  or  60  grains  or  more  to  get  desired  result, 

especially  if  the  administration  is  more  deliberate. 
The  drug  is  continued  until  results  are  obtained,  or 
In  non-urgent  cases: 

Give  m.  xxx  (2  c.c.)  of  the  tincture  of  5ss.  (15  c.c.)  of  the  infusion 
every  6  hours  for  2  days,  every  8  hours  for  3  days  and  then 
stop  or  give  one  dose  a  day.  If  desired  results  follow  at  any 
time,  stop. 

In  more  urgent  cases. 

Make  the  first  dose  3iss.-ii  (6-8  c.c.)  or  the  ticture  or  5iss.-5ii  of 
infusion  and  continue  as  above  until  results  follow. 

In  most  urgent  cases. 
Strophanthin. 

There  are  two  varieties — the  official  amorphous  strophanthin  and 
the  crystalline  strophanthin  of  Thorns,  said  to  be  identical  with 
ouabain. 
An  excellent  preparation  of  the  amorphous  strophanthin  is  that  of 

Boehringer,  in  ampoules  of  1  c.c.  containing  1  mg. 
Ouabain  is  put  up  by  several  pharmaceutical  houses  in  ampoules 

containing  Yi  mg.  and  1  mg.    The  ouabain  is  about  one-third  more 

potent  than  the  amorphous  strophanthin  given  by  the  vein. 
Roughly  1  mg.  of  amorphous  strophanthin  by  vein  equals  10  grains 

of  digitalis  and  1  mg.  of  crystalline  strophanthin  or  ouabain  equals 

13  to  14  grains  of  digitalis. 

If  given  into  muscle,  look  for  effects  in  2-3  hours;  if  in  vein,  at  once. 
The  following  doses  assume  no  digitalis  has  been  previously  given. 
Give  1  mg.  of  amorphous  strophanthin  or  Yt  mg.  of  crystalline  stro- 


204  TREATMENT  OF  ACUTE  INFECTIOUS  DISEASES 

phanthin  or  ouabain  into  the  muscle  a  dose  equal  to  about  10  grains 
of  digitalis.  Four  to  six  hours  later  repeat  with  }/£  the  first  dose. 
Begin  digitalis  by  mouth  according  to  instructions  above  at  the 
same  time  as  the  first  injection. 

If  immediate  effects  are  desired  or  edema  of  the  lungs  obtains,  give 
by  vein  about  %  of  the  dose  by  the  muscle  and  give  digitalis  by 
mouth  as  above. 

If  digitalis  has  been  given  one  reckons  the  amount  (tincture  is  10% — 
infusion  about  7  grains  to  the  ounce — digitoxin  300  times  as  strong 
as  the  leaf.)  Allow  1^  to  2  grains  a  day  as  the  rate  of  elimination. 
This  is  subtracted  from  the  total  to  estimate  the  accumulation  and 
so  the  safe  dosage  to  continue. 

Strophaathin  is  eliminated  in  36  hours;  hence,  does  not  tend  to 
accumulate  like  digitalis. 

If  strophanthin  is  not  at  hand  use  digitoxin  intravenously  (too  irritating 
for  intromuscular  or  subcutaneous  use). 

Dose  1  to  1  1/2  mg.  (gr.  1/60  gr.  1/40)  dissolve  in  1  c.c.  alcohol  and 
dilute  4  times  with  sterile  water. 

Tincture  digitalis  diluted  in  the  same  way  with  water  may  be  used. 
Dose  m.  xl-lx  (2.66-4  c.c.).  Follow  with  digitalis  by  mouth  as 
above. 

If  heart  block  occurs  give  atropine  sulphate  gr.  1/100  to  gr.  1/60 
(0.00066-0.001  Gm.).  Read  text  carefully  on  digitalis  medication. 
So-called  vaso-motor  stimulants  of  relatively  little  merit. 

Give  adrenalin  (epinephrin)  1-1000,  m.  xv  (1  c.c.)  into  the  muscle 
every  15  minutes  for  6  doses  if  necessary.  At  the  same  time  if  the 
patient  has  not  had  digitalis,  give  1/2  to  1  mg.  (gr.  1/125  gr.  1/60) 
amorphous  strophanthin  or  3/4  that  amount  of  crystalline  stro- 
phanthin or  ouabain  into  the  vein.  If  patient  has  had  digitalis 
begin  with  not  more  than  one-half  the  lesser  doses  given  above. 

Atropine  sulphate — gr.  1/100  (0.0006  Gm.)  intramuscularly. 

Caffeine. 

Use  soluble  double  salt  of  sodium  salicylate  or  sodium  benzoate, 
gr.  iii  to  gr.  v  (0.20-0.30  Gm.)  into  the  muscle  every  four,  three  or 
two  hours. 

Camphor. 

Use  a  solution  (10  per  cent,  to  20  per  cent.)  in  oil,  e.  g.,  sesame  oil 
(never  in  mineral  oil),  gr.  iii  to  gr.  v  (0.20-0.30  Gm.)  of  the  camphor 
every  four,  three  or  two  hours,  or 

Alternate  caffeine  and  camphor  as  above  at  two  hour  intervals. 

Strychnine  (less  valuable),  gr.1/40  to  gr.  1/30  (0.002-0.0015  Gm.)  into 
muscle  every  four  or  three  hours. 

Sudden  collapse. 

Adrenalin  m.  x  to  m.  xv  (0.60-1  c.c.)  into  muscle  or  m.  iii  to  m.  iv 
(0.20-0.25  c.c.)  into  a  vein. 
Heat  to  surface  of  body. 


PNEUMONIA  205 

Hot  water  bottles  or  cloths  to  the  feet. 

Heat  to  bowel  by  injections  or  irrigations  of  saline  at  110°  F.  to 

which  strong  black  coffee  is  added. 

Ammonia  (strong  water)  on  towel  flicked  before  the  nose,  then 
Caffeine  or 


Camphor  or 


in  above  doses  into  muscle. 


Strychnine 
then 
Strophanthin  in  above  dose  into  muscle. 

Pulmonary  edema. 

If  patient  is  plethoric. 

Venesection  of  12  to  16  ounces  (360-500  c.c.). 
Cup  chest.    Best  position  semi-recumbent. 
See  above  under  circulation. 

Dyspnoea. 

Due  to  pain.    (See  treatment  of  pleurisy  in  summary  above.) 
Open-air  treatment. 
Inhalations  of  oxygen. 

One  may  use  a  funnel  around  the  rim  of  which  a  strip  of  adhesive 

is  attached  like  a  skirt  to  cover  the  patient's  nose  and  mouth. 

Better  yet,  a  small  hard  rubber  tip  is  placed  in  one  nostril  and 

kept  in  place  by  adhesive  which  at  the  same  time  seals  the 

nostril.    The  other  nostril  is  sealed  by  the  hand  of  the  operator. 

Respiratory  stimulants. 

Caffeine  in  soluble  salt  of  sodium  benzoate  or  sodium  salicylate 

gr.  v  (0.33  Gm.)  into  muscle. 

Atropine  sulphate,  gr.  1/100  (0.0006  Gm.)  into  muscle. 
Strychnine  sulph.,  gr.  1/30  (0.002  Gm.)  into  muscle. 
Due  to  pulmonary  edema.    (See  above.) 

Broncho-pneumonia. 
(For  modification  of  treatment  see  text.) 
Specific  treatment. 
(See  text.) 

Complications  of  lobar  pneumonia. 
Fluid  in  the  chest. 

Confirm  signs  by  exploration. 

(Paracentesis — indications,  see  text.    Technique,  see  text.) 

Treatment  of  symptoms.     (See  Empyema.) 
Empyema.     (See  text.) 

Pericarditis. 

Indications  for  paracentesis.     (See  text.) 
Technique.     (See  text.) 
Relief  of  symptoms. 


206  TREATMENT  OF  ACUTE  INFECTIOUS  DISEASES 

Cold. 

Ice  bag — technique.     (See  text.) 

Leiter  coil.    (See  text.) 

Cold  compress.   (See  text.) 
Heat. 

Hot  water  bag.  (See  text.) 

Poultices.     (See  text.) 

Electric  pad. 

Fomentations. 
Counterirritation. 

Mustard. 
Leaf.    (See  text.) 
Paste.    (See  text.) 

Cautery.    (See  text.) 

Pneumoccocus  endocarditis. 

Treatment — that  of  a  septicemia.     (See  Chap.  XLV.) 

Thrombosis. 

Rest  of  part  affected  by  fixation. 
Enwrap  in  thick  layers  of  non-absorbent  cotton. 
Or: 
Wet  dressings  such  as  aluminum  acetate. 

Embolism. 

(See  text.) 

Meningitis. 

Treatment  of  symptoms. 

(See  Cerebro-spinal  Meningitis,  (Chap.  XXV.) 

Parotitis. 
Treatment.     (See  Mumps,  Chap.  XXIII.) 

Arthritis. 

Treat  as  in  Rheumatism.    (See  Chap.  III.) 
If  purulent,  surgery  is  indicated. 

Peritonitis. 

(See  text.) 

Jaundice.  • 

(See  text.) 

Abdominal  pain. 

(See  text.) 

Convalescence. 

Patient  should  not  sit  up  until  resolution  is  complete. 
Allow  to  sit  up  a  week  after  resolution  is  complete. 


PNEUMONIA  207 


(For  management  of  this  period,  see  text.) 

Food. 

Air. 

Return  to  work.    (See  text.) 

Relapses. 

(See  text.) 

Prophylactic  use  of  Pneumococcus  vaccines. 
(See  text.) 


CHAPTER  X 

STREPTOCOCCUS  PNEUMONIA 

THE  terrible  epidemics  of  measles  that  ravished  our  camps  during 
the  late  war,  afforded  an  opportunity  for  the  study  of  the  complicating 
pneumonias  never  before  offered.  These  were  all  due  to  the  secondary 
invasion  of  the  stieptococcus  hemolyticus  although  pneumococci  may 
induce  the  same  lesion  and  an  identical  pathology  was  found  in  many 
broncho-pneumonias  in  the  influenza  epidemic  in  which  pure  culture  of 
influenza  bacilli  was  found;  nor  were  these  pneumonias  confined  to 
measle  cases  exclusively;  on  the  contrary  they  constituted  in  some  camps 
veritable  epidemics  of  primary  pneumonia.  When  I  read  the  careful 
reports  of  the  morbid  anatomy  of  these  cases  made  by  MacCallum,  my 
mind  goes  back  to  the  insistent  teaching  of  Delafield  in  my  student 
days  as  to  what  constituted  the  essence  of  broncho-pneumonia  with  an 
admiration  that  only  brightens  the  halo  with  which  we  always  saw  our 
great  teacher  invested.  Dr.  MacCallum  has  graciously  acknowledged 
the  accuracy  and  conciseness  of  Dr.  Delafield's  description  of  broncho- 
pneumonia  made  in  1884.  The  distinguishing  characteristic  of  this 
broncho-pneumonia  is  that  it  is  an  interstitial  process  from  the  first  and 
is  located  primarily  in  the  walls  of  the  bronchioles  and  of  the  alveoli 
adjacent.  If  the  walls  of  the  bronchioles  be  examined,  there  will  be  found 
intense  congestion  of  the  vessels,  an  infiltration  with  mononuclear  cells,  a 
new  formation  of  connective  tissue  and  a  new  formation  of  blood  vessels. 
This  is  a  productive  lesion,  a  protective  and  reparative  process.  The 
lumen  of  the  bronchioles  contain  an  exudate  of  white  cells  and  fibrin 
in  which  are  enmeshed  great  numbers  of  streptococci.  In  severe  cases 
the  lining  membrane  may  become  necrotic,  forming  a  pseudo-membrane. 
The  walls  of  the  alveoli  adjacent,  that  is  surrounding  and  radiat- 
ing from  the  wall  (not  those  constituting  a  continuance  of  the  bronch- 
ioles, their  terminal  alveoli),  are  also  infiltrated  like  the  wall  of 
the  bronchus  with  mononuclear  cells  and  new  connective  tissue;  the 
alveolar  cavities  contain  proliferated  and  desquamated  epithelial 
cells  from  its  walls  together  with  an  exudate  containing  dense  fibrin, 
red  cells  and  a  few  mononuclear  cells,  but  streptococci  are  curiously 
absent.  Organization  of  this  exudate  takes  place  quickly.  Atelec- 
tasis  occurs  in  those  areas  that  are  cut  off  from  air  by  obstructed  bronchi 
and  constitute  a  prominent  feature  of  the  process;  an  exudate  fills  the 


STREPTOCOCCUS  PNEUMONIA  209 

air  spaces  and  organizes; — small  hemorrhages  may  occur  into  infiltrated 
areas.  All  this  gives  rise  to  the  characteristic  nodules  seen  in  the  gross 
specimen.  When  these  are  crowded  together  the  appearance  is  that  of  an 
extensive  and  continuous  consolidation. 

Lymphatics.  These  channels  running  from  the  pleurae  to  the 
nodes  at  the  roots  of  the  lungs,  along  the  interlobular  septa,  bronchi, 
and  blood  vessels,  become  infected  and  thrombosed  and  the  pleurae  are 
infected  through  them,  the  bacteria  growing  by  direct  extension  through 
the  thrombosed  lymphatics  against  the  direction  of  the  current.  Strep- 
tococci are  found  in  numbers  in  these  vessels.  Organization  occurs  in  the 
septa  along  which  they  run  giving  them  great  definition  on  section. 
The  blood  vessels  in  the  lung  are  not  thrombosed. 

Pleurae.  Infection  of  the  pleura  is  characterized  by  an  effu- 
sion of  thin  turbid  fluid,  gi  eenish-brown  in  color,  containing  many  strep- 
tococci. It  comes  on  promptly  in  large  quantity,  compressing  the  lung. 
Organization  occurs  rapidly  here,  causing  great  thickening,  dense  ad- 
hesions and  encapsulation  of  pus. 

Necrosis.  Portions  of  the  lung  may  necrose  and  discharge  by 
the  bronchi  with  excavation  and  this  may  break  through  into  the  pleura, 
causing  pyopneumothorax.  MacCallum  describes  a  second  type  of 
streptococcus  pneumonia,  which  he  terms  lobular  and  defines  as  "a 
patchy  consolidation"  with  an  exudate  "similar  to  that  which  when 
diffusely  distributed  over  a  whole  lobe  constitutes  a  lobar  consolidation." 
Streptococci  in  large  numbers  are  found  in  the  alveoli.  There  were  no 
interstitial  changes  but  much  necrosis  of  lung  tissue.  Pleurisy  often 
occurred,  but  without  organization.  This  lesion  may  occur  uncompli- 
cated or  may  be  mixed  up  with  interstitial  broncho- pneumonia. 

Empyema.  The  term  has  been  applied  to  all  the  fibrino-purulent 
exudates  of  these  streptococcal  pleurisies.  Though  thin  at  first  they 
become  distinctly  purulent  in  time.  MacCallum  states  that  in  acute 
streptococcus  pneumonia  cases  dying  inside  of  eight  days,  the  pleural 
cavities  are  found  free  from  effusion,  but  if  the  case  lasts  from  ten 
days  to  two  weeks  or  more  an  exudate  was  nearly  always  found.  The 
appearance  of  fluid  in  the  early  stages  has  been  likened  to  turbid  urine, 
unstrained  bouillon,  muddy  water  and  thin  pea-soup;  later  it  becomes 
thick  and  more  purulent  and  when  localized  often  a  thick  whitish  green 
pus.  When  the  chest  is  opened  and  it  has  become  secondarily  infected 
with  putrefactive  organisms,  it  becomes  foul  and  often  bluish  green. 
Organization  is  rapid  and  extensive,  causing  adhesions  and  sacculations 
of  pus.  When  large  accumulations  of  fluid  occurred  before  adhesions 
formed,  the  lung  became  extremely  collapsed  and  flattened  against  the 
mediastinal  tissues. 


210  TREATMENT  OF  ACUTE  INFECTIOUS  DISEASES 

It  should  be  kept  in  mind  that  encapsulations  of  pus  between  the 
median  surface  of  the  lung  and  pericardium  seems  to  be  common  and 
unless  this  possibility  be  kept  in  mind  the  signs  and  symptoms  might 
be  overlooked.  Similar  encapsulation  may  occur  posteriorly  between 
lung  and  mediastinum  and  between  the  inferior  surface  of  the  lung 
and  the  diaphragm. 

Pathology  of  Other  Organs.  The  larynx  may  be  involved  with 
ulceration  of  the  vocal  cords.  This  was  seen  in  seven  cases  with  measles 
and  caused  aphonia. 

Tonsils  are  not  commonly  involved. 

Otitis  media  is  not  rare. 

Peritonitis  seems  not  to  be  infrequent;  presumably  the  infection  comes 
through  the  lymphatics  of  the  diaphragm. 

Blood  cultures  even  in  severe  cases  remain  sterile,  unless  taken  just 
before  death,  thus  affording  a  contrast  to  the  blood  findings  in  pneu- 
mococcus  lobar  pneumonia. 

I  have  dwelt  on  the  pathology  of  this  condition  in  more  detail  because 
it  covers  many  of  the  pneumonias  seen  in  the  influenza  epidemic,  in  the 
severe  form  of  measles,  which  seems  to  induce  a  peculiar  susceptibility 
to  it  and  lowered  resistance  toward  it,  as  is  seen  in  its  most  malignant 
form.  Indeed,  death  in  measles  depends  largely  on  pulmonary  infection. 
It  is,  too,  the  pneumonia  we  meet  with  in  whooping  cough  and  diphtheria 
and  occasionally  in  scarlet  fever.  It  occurs  also  as  a  primary  infection. 

The  Symptomatology  varies  with  the  virulency  of  the  infection 
and  the  extent  of  the  process.  In  the  epidemic  cases  of  primary  pneu- 
monia the  disease  may  be  almost  fulminating  in  its  course;  dyspnoea  is 
intense  and  cyanosis  very  marked.  This  is  true  of  the  form  sometimes 
designated  as  capillary  bronchitis  when  the  involvement  of  each  bron- 
chiole is  like  having  a  ligature  tightened  about  it;  so  too,  when  the 
pleural  effusion  causes  compression  and  atelectasis. 

In  the  secondary  cases  the  onset  is  more  gradual;  but  the  patient 
becomes  appreciably  sicker  and  the  characteristic  symptoms  of  the 
pulmonary  involvement  declare  themselves.  One  may  expect  more 
dyspnoea,  more  cough  and  a  more  rapid  pulse  than  in  lobar  pneumonia, 
a  longer  course,  a  more  certain  empyema  and  defervescnece  by  lysis. 

TREATMENT 

The  case  is  treated  as  in  lobar  pneumonia.  There  is  no  specific  treat- 
ment. 

The  support  of  the  circulation  is  urgent  and  the  measures  already 
specified  are  to  be  carried  out  energetically. 


STREPTOCOCCUS  PNEUMONIA  211 

Dyspnoea  and  cyanosis  indicate  the  use  of  oxygen;  for  details  of  its 
administration  see  Influenzal  Pneumonia  and  Summary.  Cough  is  much 
more  troublesome  than  in  lobar  pneumonia.  For  a  discussion  of  its 
treatment  see  under  Lobar  Pneumonia  and  Influenza  Pneumonia.  Em- 
pyema  requires  urgent  and  immediate  treatment. 

EMPYEMA 

(STREPTOCOCCUS  AND  INFLUENZA  TYPES) 
BY  DR.  ALFRED  S.  TAYLOR 

The  conditions  in  these  types  of  empyema  are  so  different  from  those 
in  the  pneumococcus  type  that  the  method  of  procedure  must  vary 
distinctly.  The  effusion  usually  occurs  to  considerable  extent  before  the 
pneumonic  consolidation  has  resolved.  The  effusion  while  virulently 
infected  does  not  become  frankly  purulent  at  so  early  a  stage  and  there- 
fore adhesions  between  the  lung  and  pleura  do  not  occur  at  so  early  a 
period  as  in  pneumococcus  empyema.  Because  of  this  failure  of  adhe- 
sions to  form,  thoracotomy  with  resulting  entrance  of  air  into  the  pleural 
cavity  causes  not  only  very  marked  collapse  of  the  lung  on  the  same  side 
but  also  causes  marked  displacement  of  the  mediastinum  and  heart 
toward  the  opposite  side  with  great  resulting  embarrassment  of  the 
respiratory  and  circulatory  functions.  The  rationale  of  treatment 
therefore  consists  in  the  following: — 

The  considerable  effusion  which  occurs  early  causes  marked  embar- 
rassment of  respiration  and  circulation  and  must  therefore  be  relieved. 
This  is  best  accomplished  by  aspiration,  repeated  at  such  intervals  as  is 
indicated  by  the  refilling  of  the  chest  with  fluid.  Preceding  aspiration 
X-Ray  pictures  of  the  chest  should  be  taken  to  determine  definitely  the 
situation  and  amount  of  fluid  in  the  cavity.  As  a  rule  no  form  of  suction 
apparatus  is  necessary  in  evacuating  the  fluid.  A  good  sized  aspirating 
needle,  8  to  12  cm.  long,  with  a  somewhat  bluntly  beveled  point,  may  be 
used  for  the  puncture;  Yi  per  cent,  novocaine  solution  may  be  injected 
into  the  skin  and  subcutaneous  tissues  at  the  point  chosen  for  puncture, 
which  is  usually  best  placed  in  the  8th  or  9th  intercostal  space  at  the 
posterior  axillary  border.  The  aspirating  needle  is  inserted  until  it  is 
felt  to  puncture  the  parietal  pleura.  As  a  rule  the  fluid  will  begin  to 
flow  spontaneously.  If  it  does  not  a  wire  may  be  pushed  through  the 
needle  to  make  sure  its  lumen  is  patent.  If  the  fluid  does  not  then  run 
one  may  attach  a  syringe  and  cause  suction  to  start  the  flow.  A  large 
syringe  of  the  Janet  type  may  be  used  with  a  small  segment  of  rubber 
tube  to  connect  between  the  needle  and  the  syringe  tip.  If  necessary 


212  TREATMENT  OF  ACUTE  INFECTIOUS  DISEASES 

this  syringe  may  be  used  repeatedly  until  the  chest  is  evacuated.    This 
evacuation  should  take  place  not  too  rapidly  in  order  to  avoid  any  sudden 
change  in  thev  pressure  conditions  within  the  chest.    At  the  first  sign  of 
respiratory  or  circulatory  distress  the  aspiration  should  be  stopped  for 
the  time  being.   Another  simple  form  of  apparatus  for  aspirating  consists 
in  having  a  bottle  which  will  hold  one  or  two  litres  with  a  wide  mouth, 
fitted  with  a  rubber  stopper,  which  can  be  made  air-tight.    This  stopper 
is  perforated  so  as  to  permit  the  insertion  of  a  glass  tube  which  fits  air- 
tight.   Connected  with  the  glass  tube  is  a  rubber  tube,  the  walls  of  which 
are  moderately  rigid.    This  tube  carries  a  clamp  which  shuts  it  com- 
pletely.   If  now  a  slight  amount  of  alcohol  is  put  in  the  bottle  and  the 
bottle  is  rolled  around  until  the  alcohol  covers  the  inside  surface,  and 
then  the  bottle  is  placed  upon  a  table,  and  the  operator,  holding  the 
rubber  stopper,  just  outside  the  bottle  mouth,  holds  a  lighted  match  to 
the  mouth  of  the  bottle,  the  alcohol  vapor  explodes  and  the  rubber 
stopper  is  immediately  sucked  into  the  neck  of  the  bottle  fitting  air-tight 
so  that  a  distinct  vacuum  exists  within  the  bottle.    When  the  aspirating 
needle  has  been  inserted  into  the  pleural  effusion  the  rubber  tube  may  be 
slipped  over  the  end  of  the  needle  and  the  clamping  apparatus  on  the 
tube  gradually  released  until  the  vacuum  bottle  begins  to  aspirate  the 
fluid  from  the  chest.    This  constitutes  a  simple  and  usually  very  effective 
aspirating  outfit.    It  requires  only  a  moderate  amount  of  practice  to 
obtain  a  good  vacuum.    The  clamp  must  be  released  somewhat  gradually 
because  if  it  were  removed  at  once  and  if  the  vacuum  within  the  bottle 
happened  to  be  very  marked,  the  suction  would  be  too  sudden  for  the 
comfort  of  the  patient.     Aspiration  must  be  repeated  with  sufficient 
frequency  to  relieve  the  mechanical  distress  of  the  patient.    When  the 
fluid  becomes  distinctly  purulent,  it  is  usually  the  case  that  adhesions 
have  formed  between  the  lung  and  parietal  pleura  and  thoracotomy  may 
be  done  with  safety.    The  procedure  followed  is  that  described  under 
pneumococcus  empyema.    In  the  after-treatment  of  this  streptococcus 
type  of  empyema  the  use  of  Dakin's  solution  is  of  much  greater  value 
than  in  pneumococcus  cases  inasmuch  as  it  kills  off  the  virulent  infec- 
tion much  more  promptly  and  will  hasten  the  result.    For  a  detailed 
description  of  the  Dakin  technique  in  these  cases  the  reader  is  referred  to 
the  standard  works  on  the  subject.    Those  who  are  familiar  with  it  can 
apply  it  without  specific  instruction.    Those  who  are  not  familiar  with  it 
should  not  attempt  to  gain  experience  in  this  type  of  case.    In  every 
respect  this  type  of  empyema  is  apt  to  be  much  more  troublesome  than 
the  usual  pneumococcus  empyema.    There  are  much  more  likely  to  be 
isolated  pockets  of  pus  which  frequently  do  not  communicate  freely  with 
the  mam  empyema  cavity,  so  that  the  drainage  of  the  main  cavity  may 


STREPTOCOCCUS  PNEUMONIA  213 

appear  to  be  progressing  very  satisfactorily  but  the  patient's  general 
condition  does  not  improve  correspondingly.  X-Ray  pictures  will 
usually  indicate  the  presence  of  additional  pockets.  Oftentimes  they  will 
also  indicate  small  multiple  abscesses  in  the  lung  substance.  When  the 
trouble  is  due  to  pockets  of  pus  in  the  pleural  cavity  these  must  be 
drained  either  by  opening  them  by  instrumentation  through  the  original 
thoracotomy  wound  or  by  direct  approach  by  means  of  another  opera- 
tion. The  case  is  thus  followed  until  the  wound  is  healed  and  the  pa- 
tient's general  condition  indicates  no  remaining  disturbance.  If  the 
Dakin  technique  is  followed  it  had  been  found  that  when  the  controlling 
smear  shows  only  from  1  to  4  bacteria  to  the  field  the  wound  may  be 
secondarily  sutured  even  if  the  cavity  is  still  of  some  size.  In  a  high 
percentage  of  cases  so  sutured  the  cavity  remains  sterile,  the  lung  ex- 
pands with  fair  rapidity,  and  the  cavity  disappears  through  absorption 
of  the  ah*  content  and  the  healing  together  of  the  lung  and  parietal  pleura. 

In  the  small  remaining  percentage  of  cases  it  is  necessary  to  reopen  the 
wound  because  of  some  further  purulent  exudate. 

In  this  streptococcus  type  of  empyema  air-tight  drainage  shows  up 
to  the  best  advantage.  It  permits  free  escape  of  the  contents  of  the 
empyema  cavity  and  prevents  the  ingress  of  any  air  which  might  cause 
collapse  of  the  lung  and  displacement  of  the  mediastinum  to  the  opposite 
side  inasmuch  as  the  adhesions  between  the  lung  and  parietal  pleura  do 
not  appear  so  early  and  are  not  as  firm  as  in  the  case  of  pneumococcus 
empyema.  This  air-tight  drainage  is  accomplished  in  many  different 
ways.  Many  of  the  methods  are  complicated,  but  there  are  three  simple 
methods  which  answer  the  needs  very  satisfactorily.  The  simplest 
method  consists  in  making  a  stab  wound  through  the  8th  intercostal 
space  in  the  posterior  axillary  line.  This  stab  wound  is  made  just  large 
enough  to  permit  one  to  crowd  in  a  rubber  drainage  tube  1  cm.  or  1.5  cm. 
in  diameter,  the  walls  of  which  are  fairly  rigid.  This  tube  is  pushed  in 
through  the  stab  wound  by  means  of  a  clamp  which  folds  it  to  a  com- 
paratively small  size.  It  is  pushed  in  so  that  it  protrudes  1  to  2  cm. 
within  the  parietal  pleura.  When  the  clamp  is  withdrawn  the  tube 
unfolds  and  fills  the  wound  so  that  it  is  air-tight  and  water-tight.  The 
tube  is  then  supported  by  adhesive  plaster  strips  attached  to  it  and  the 
skjn  so  as  to  prevent  displacement.  The  tube  is  sufficiently  long  to  lead 
from  the  wound  to  a  bottle  on  the  floor  beneath  the  bed.  In  this  bottle 
is  placed  a  sterile,  or  better,  a  slightly  antiseptic  fluid,  sufficient  to  keep 
the  lower  end  of  the  tube  submerged.  There  is  opportunity  for  free 
escape  of  the  empyema  fluid  but  no  air  can  get  into  the  pleural  cavity. 
If  one  wishes  to  use  Dakin's  solution  a  glass  Y  tube  may  be  fitted  into 
any  portion  of  this  drainage  tube.  The  arm  of  the  Y  tube  through  which 


214  TREATMENT  OF  ACUTE  INFECTIOUS  DISEASES 

Dakin's  solution  is  instilled,  is  covered  with  a  rubber  tube  which  is 
clamped  so  as  to  be  air-tight  and  is  open  only  during  the  instillation  of 
Dakin's  solution. 

When  the  patient  is  able  to  sit  up  the  bottle  of  fluid  can  be  placed 
under  the  chair  and  the  drainage  continued.  In  some  cases,  as  in  chil- 
dren, the  patient  may  be  up  and  about  with  the  drainage  tube  still 
in  situ  and  the  bottle  fastened  to  him  so  that  he  can  get  about  with 
reasonable  comfort.  This  method  while  satisfactory  in  many  cases  does 
not  serve  where  there  are  one  or  more  pockets  almost  shut  off  from  the 
main  empyema  cavity.  In  these  cases  which  may  be  detected  by  proper 
X-Ray  pictures,  it  is  preferable  to  do  rib  resection,  as  described  in  pneu- 
mococcus  empyema.  The  cavity  may  then  be  entirely  explored  and 
accessory  cavities  opened  so  as  to  give  free  drainage  through  the  main 
cavity.  The  wound  is  then  sutured  tight  except  for  sufficient  space  to 
carry  rubber  drainage  tube  1  to  1.5  cm.  in  diameter  with  fairly  rigid  walls. 
In  order  to  insure  air-tight  closure  of  the  sutured  wound  a  piece  of  rubber 
dam  10  cm.  square  is  perforated  with  a  small  punch  hole  at  its  centre. 
The  drainage  tube  is  pushed  through  this  punch  hole  which  then  becomes 
an  air-tight  fitting  around  the  tube.  For  further  security  the  rubber  dam 
may  be  glued  to  the  tube  by  using  a  few  drops  of  chloroform  around  the 
joint  or  more  simply  by  tying  a  linen  thread  around  the  dam  and  the  tube 
so  as  to  make  sure  of  tight  closure.  The  dam  is  so  placed  on  the  tube 
that  when  the  tube  is  inserted  through  the  wound  so  as  to  protrude 
1  to  2  cm.  within  the  parietal  pleura  the  rubber  dam  is  just  flush  with  the 
skin  surface.  This  distance  varies  with  the  thickness  of  the  tissues  of 
the  person  operated  upon  and  must  be  decided  at  the  time  of  operation. 
After  the  tube  is  inserted  and  the  rubber  dam  lies  spread  over  the  sur- 
rounding skin,  broad  strips  of  adhesive  plaster  are  used  to  stick  the  edges 
of  the  rubber  dam  to  the  skin.  This  also  gives  a  water-tight  and  air- 
tight drainage.  The  tube  is  led  into  a  bottle  of  solution  as  previously 
described.  Both  of  these  methods  keep  the  patient  perfectly  dry  and 
uncontaminated  by  the  empyema  fluid.  A  third  method,  which  was 
modified  by  the  writer  from  the  procedure  described  by  Dr.  Lund  of 
Boston  gives  a  perfectly  satisfactory  air-tight  drainage  without  the  use 
of  any  apparatus.  A  curved  incision  is  made  through  the  skin  and  sub- 
cutaneous fat  over  the  level  of  the  9th  rib.  This  flap  is  dissected  up  and 
the  skin  above  it  is  undermined  and  retracted  up  to  the  level  of  the  8th 
rib.  The  incision  is  now  carried  down  through  the  muscles  to  the  rib, 
8  to  10  cm.  of  which  is  now  resected  as  previously  described  under 
pneumococcus  empyema.  After  the  rib  has  been  resected  the  parietal 
pleura  is  loosened  from  the  wound  upward  to  beneath  the  7th  rib  and 
then  a  rectangular  flap  of  pleura  is  cut  and  turned  from  above  downward 


STREPTOCOCCUS  PNEUMONIA  215 

so  as  to  make  a  facing  for  the  muscular  surface  denuded  by  elevating  the 
skin.  This  pleural  flap  is  held  down  by  a  few  catgut  sutures.  It  seems 
to  prevent  too  rapid  healing  of  the  skin  flap  to  the  underlying  muscles. 
It  also  creates  a  good  vent  hole  for  the  escape  of  the  empyema  contents. 
After  the  cavity  has  been  explored,  and  accessory  cavities,  if  present, 
have  been  opened  into  the  main  cavity,  the  skin  flap  is  allowed  to  fall 
back  into  place.  Its  corners  are  closed  by  means  of  silk  sutures.  The 
skin  flap  now  acts  as  a  flap  valve.  Whenever  the  patient  coughs  or 
strains,  the  contents  of  the  empyema  cavity  are  extruded  freely.  When- 
ever inspiration  occurs  the  skin  flap  immediately  falls  against  the  muscle 
tissues  beneath  and  air-tight  closure  occurs  immediately.  This  is  readily 
demonstrated  on  the  operating  table.  A  soft  ring  of  cotton  is  made 
sufficiently  large  in  diameter  to  entirely  circumscribe  the  wound  and  flap 
valve.  This  is  fastened  to  the  skin  by  bands  of  adhesive  plaster.  Ab- 
sorbent dressings  are  now  applied  over  this  ring  and  fastened  by  a  binder. 
These  dressings  are  changed  as  often  as  necessary  to  keep  the  patient  dry 
and  comfortable.  Every  second  day  a  pair  of  blunt  flat  scissors  are 
slipped  beneath  the  skin  flap  to  make  sure  that  it  has  not  become  ad- 
herent to  the  underlying  structures  to  the  disadvantage  of  the  drainage. 
By  this  method  after  free  vacuation  is  obtained  no  air  ever  gets  into  the 
chest  and  the  lung  expands  and  comes  down  rapidly  to  its  proper  posi- 
tion. The  patient  is  free  from  apparatus  and  therefore  can  turn  in  bed 
and  can  sit  up  with  much  less  discomfort.  The  only  disadvantage  lies 
in  the  fact  that  the  patient  is  wet  from  the  discharge  a  certain  amount  of 
time.  After  the  first  48  hrs.  the  discharge  is  comparatively  slight.  This 
has  proven  an  extremely  satisfactory  method  in  the  hands  of  a  number  of 
men.  All  of  these  different  procedures  may  be  done  with  local  anes- 
thesia as  previously  described.  General  anesthesia  may  be  used  ac- 
cording to  the  judgment  of  the  operating  surgeon.  In  all  of  these  meth- 
ods also  respiratory  exercises  with  the  aid  of  the  Wolff  bottles  may  be 
used,  as  previously  advised.  On  the  whole  one  of  these  three  methods  of 
air-tight  drainage  is  to  be  much  preferred  to  the  resection  of  a  rib  with 
open  drainage. 

SUMMARY 

No  specific  treatment. 

'  For    detailed    treatment    see    Lobar  Pneumonia,   and    Influenzal 
Pneumonia.    (Chaps.  IX  and  XII.) 

Support  of  the  circulation  urgent — measures  specified  must  be  under- 
taken early  and  energetically. 

Dyspnoea  and  cyanosis.     Use  oxygen.     (See  Influenzal  Pneumonia.) 

Empyema. 
(See  text.) 


CHAPTER  XI 

THE  TREATMENT  OF  GRIP  OR  SPORADIC  INFLUENZA1 

OF  grip  or  influenza  there  are  two  statements  to  be  made  which  I 
think  no  one  will  attempt  to  gainsay;  first,  that  of  all  the  acute  infectious 
diseases  with  which  we  have  to  deal,  it  is  the  most  common;  secondly, 
that  no  other  acute  infectious  disease  is  so  protean  in  its  manifestations 
as  this  ubiquitous  malady. 

Much  confusion  has  arisen  in  the  use  of  these  two  terms,  grip  and 
influenza.  By  most  men  they  are  used  synonymously,  but  many  insist 
that  influenza  is  applicable  only  to  that  infection  caused  by  the  organism 
of  Pfeiffer,  the  influenza  bacillus.  If  their  contention  is  sustained,  then 
we  see  this  disease  relatively  infrequently,  and  what  we  consider  as  such 
should  receive  another  appellation  and  "grip"  might  be  so  used.  Now, 
we  do  have  a  common  clinical  entity,  characterized  by  suddenness  of 
onset,  aching  pains  in  the  back  and  limbs,  headache,  high  fever,  prostra- 
tion, some  catarrhal  symptoms  in  the  respiratory  tract  and  followed  by 
weakness  and  depression  out  of  proportion  to  the  other  symptoms  and 
which  may  be  accompanied  or  followed  by  serious  involvement  of 
important  organs  or  systems.  These  attacks  are  accompanied  by  the 
presence  of  one  or  the  other  or  of  a  combination  of  several  organisms,  in 
such  numbers  and  so  distributed  as  to  warrant  the  supposition  that  they 
stand  in  causal  relationship  to  the  disease;  and  among  these  organisms 
is  the  bacillus  of  Pfeiffer,  but  in  by  no  means  the  majority  of  the  cases. 
Beside  this  organism  may  be  found  the  pneumococcus,  the  streptococcus 
pyogenes,  the  streptococcus  mucosus  capsulatus  or  the  micrococcus 
catarrhalis.  In  no  way  does  the  attack,  with  reference  to  the  onset, 
characteristic  pains  and  aches,  prostration,  after  effects  or  complications, 
differ  in  one  case  or  another  sufficiently  to  guarantee  a  diagnosis  of  the 
organism  concerned.  Moreover,  the  influenza  bacillus  has  been  found  in 
other  conditions  that  do  not  present  the  clinical  picture  of  grip.  Whether 
we  are  dealing  with  one  or  the  other  bacterium  can  be  determined  only 
by  culture.  At  the  present  we  have  no  specific  treatment  for  influenza 

1  This  chapter  deals  with  the  infections  met  with  each  winter,  loosely  termed 
grip  or  influenza  and  attributed  to  more  than  one  form  of  infecting  organism. 
The  epidemic  influenza  as  'seen  in  1889-90  and  in  1918-19  is  dealt  with  in  the 
succeeding  chapter. 


GRIP  217 

and  find  ourselves  limited  to  the  effort  to  afford  relief,  to  prevent  compli- 
cations, or  treat  them  if  they  do  occur. 

Therapy.  All  that  follows,  then,  is  applicable  to  the  clinical 
grip  and  if  I  use  both  terms,  it  will  be  understood  that  they  are  used 
synonymously. 

Rest.  An  attack  of  grip  of  average  severity  compels  a  patient  to  seek 
rest  and  seek  it  in  bed;  but  in  lesser  attacks,  often  termed  common 
colds — and,  indeed,  the  border  line  between  the  common  cold  and  grip  is 
by  no  means  clear  cut — the  patient  may  insist  on  keeping  about  and 
endeavor  to  attend  to  his  business.  That  every  patient  with  a  cold  in 
the  head  should  go  to  bed  is  absurd,  but  if  the  so-called  cold  is  accom- 
panied by  signs  of  intoxication,  aches,  pains,  prostration  and  temper- 
ature out  of  proportion  to  the  local  manifestations,  then  the  diagnosis  is 
warranted,  as  at  least  connoting  a  more  serious  infection,  of  which  the 
complications  or  sequelae  are  to  be  feared,  and  the  patient  should  be  or- 
dered to  bed  until  his  temperature  is  normal,  his  protests  being  met  by  a 
presentation  of  the  facts  and  possibilities  in  the  case. 

The  typical  attack  of  influenza  is  usually  abrupt,  sometimes  like  a 
bolt  out  of  the  blue,  ushered  in  with  chilly  sensations  and  decided  ma- 
laise. 

The  patient  should  be  put  to  bed,  a  hot  water  bag  put  at  his  feet, 
a  drink  of  hot  tea,  hot  water  and  a  teaspoonful  or  two  of  whiskey  or 
a  hot  lemonade  with  or  without  whiskey  given,  and  blankets  added 
to  the  covering  until  the  febrile  reaction  begins.  With  the  fever  comes 
the  headache,  the  pains  in  the  back  and  bones  that  makes  the  patient 
feel  as  if  he  had  been  mauled  and  bruised,  and  the  discomforts  of  the 
elevated  temperature.  The  head  is  often  confused  and  a  mild  delirium 
may  occur. 

A  cool  sponge  bath  or  one  with  tepid  water  or  one  containing 
a  little  alcohol  applied  to  the  whole  body  or  to  the  face,  arms  and  legs 
gives  some  relief.  Cold  cloths  are  placed  on  the  forehead  to  relieve 
the  headache  or  an  ice  bag  may  be  used.  Bits  of  cracked  ice  are  sucked 
or  small  amounts  of  cold  water  taken  frequently. 

A  saline  cathartic  should  be  given,  in  the  shape  of  a  Seidlitz 
powder,  a  full  glass  of  liquor  magnesii  citratis,  or  a  half  ounce 
(15  Gm.)  of  either  Rochelle  salt  or  Epsom  salt  in  a  half  to  three- 
fourths  of  a  glass  of  water. 

Diet.  At  the  onset  of  the  attack  food  should  not  be  offered;  and 
the  anorexia  should  be  taken  as  an  indication  that  the  body  is  not  ready 
to  entertain  it.  After  the  first  day,  however,  fluids  in  the  shape  of  milk 
or  gruels  may  be  given  and  later  soups,  eggs,  and  cereals. 

When  the  temperature  has  subsided  the  diet  should  be  made  liberal, 


218  TREATMENT  OF  ACUTE  INFECTIOUS  DISEASES 

for  the  loss  of  flesh  may  have  been  considerable,  and  it  must  be  appre- 
ciated that  the  2,500  or  more  calories  that  the  body  will  have,  even  in  the 
weakened  state,  must  come  from  somewhere,  out  of  its  own  tissue,  if  not 
provided  f of  in  its  food.  *? 

SYMPTOMATIC  TREATMENT 

Sthenic  Period  of  Toxemia. — Drugs.  In  no  other  acute  in- 
fectious disorder  do  the  coal-tar  preparations  work  so  happily  to  the 
comfort  of  the  patient,  as  in  this. 

The  sudden  fever,  the  severe  headache  and  the  racking  pains  of 
body  and  limbs  all  indicate  these  antipyretics  and  analgesics. 

There  is  no  class  of  drugs  more  abused  or  misused  than  the  antipjr- 
retics.  In  a  certain  number  of  conditions  when  properly  used  they  are 
invaluable,  but  like  most  drugs  of  real  worth  they  are  rife  with  danger 
when  administered  carelessly  or  in  ignorance. 

The  three  best  known  antipyretics  are  acetanilid,  sometimes 
called  antifebrin,  antipyrin  and  phenacetin. 

This  is  also  the  order  of  their  potency  and  of  their  toxicity.  From 
these  three  have  come  numerous  derivatives,  made  by  introducing  a 
radicle  into  their  structure  or  substituting  one  radicle  for  another,  in  the 
effort  to  enhance  their  pharmacological  value  and  at  the  same  time 
diminish  their  dangers.  With  them  have  been  combined  other  drugs  of 
a  different  pharmacological  action  in  the  effort  to  get  the  two  in  one 
preparation,  as  for  example  when  antipyrin  and  chloral  are  combined  to 
form  hypnal  to  get  a  substance  which  will  produce  sleep  in  the  presence 
of  pain,  or  salicylic  acid  and  antipyrin  are  combined  to  form  salipyrin  to 
enhance  the  value  of  salicylic  acid  in  the  relief  of  pain  in  rheumatism. 

So  quickly  and  abundantly  have  these  preparations  come,  so  ardently 
have  they  been  welcomed  and  praised,  so  rapidly  have  they  been  aban- 
doned that  it  is  difficult  to  set  an  appreciation  on  more  than  a  few  of 
the  group. 

Personally,  I  rarely  use  for  any  purpose  any  other  than  the  three 
first  mentioned. 

In  grip  any  one  may  be  used;  better  results  are  obtained  from  small 
doses  frequently  given  than  from  large  doses.  Which  of  these  is  the 
better  I  cannot  say,  but  one  will  find  oneself  giving  preference  to  one  or 
the  other  more  and  more  and  that  will  represent  the  reliance  that  comes 
with  familiarity. 

In  grip  my  preference  is  for  the  most  toxic  and  potent  of  these  three — 
namely,  acetanilid,  but  I  give  it  in  small  quantities  at  frequent 
intervals. 


GRIP  219 

The  results  have  been  so  good,  year  in  and  year  out,  that  I  have  felt 
no  inclination  to  experiment  with  the  others. 

I  have  no  doubt  that  I  should  have  had  just  as  good  reports  to  offer 
from  one  of  the  other  preparations  had  I  accustomed  myself  to  their 
usage.  My  favorite  prescription  runs  thus: — 

Acetanilidi 1 . 50  gr.  xxiiss. 

Sodii  Bicarbonatis 1 . 00  gr.  xv. 

Caffeinae  Citratee 50  gr.  viiss. 

M.  et  Divide  in  capsulas  no.  xv. 


Each  of  these  capsules,  then,  contains  \y%  grains  (0.10  Gm.)  of  ace- 
tanilid,  which  is  a  very  small  dose,  one  grain  of  bicarbonate  of  soda, 
which  possibly  lessens  the  slight  irritant  effect  of  acetanilid  on  the  gastric 
mucous  membrane;  at  any  rate  it  is  given  on  that  supposition,  and  Y^ 
grain  (0.030  Gm.)  of  citrated  caffeine,  for  two  reasons:  First,  as  a  prophy- 
lactic, to  counteract  the  slight  depressing  effect  that  is  induced  in  some 
susceptible  individuals  by  acetanilid,  and  secondly,  because  it  is  itself 
an  analgesic. 

The  fact  that  caffeine  is  a  circulatory  stimulant  naturally  led  to  the 
supposition  that  its  presence  in  a  prescription  containing  acetanilid  or 
other  antipyretic  afforded  an  antidote  in  some  measure  to  the  toxic 
effects  of  the  latter.  Physicians  have  been  influenced  by  this  idea  to 
permit  patients  to  take  doses  of  these  antipyretics,  when  so  "sheltered," 
of  a  size  they  would  fear  to  administer,  if  given  alone. 

Worth  Hale1  experimenting  on  the  toxicity  of  acetanilid  when  ad- 
ministered alone,  when  given  with  caffeine,  with  sodium  bicarbonate  or 
when  all  three  are  combined,  obtained  results  that  make  us  pause  in  the 
use  of  the  larger  doses  of  these  drugs. 

In  animals  he  could  show  that  the  addition  of  caffeine  to  acetanilid 
caused  death  by  the  latter  more  quickly  or  in  smaller  dose,  while  bicar- 
bonate lessened  the  toxicity  of  acetanilid. 

In  white  mice  he  found  acetanilid  and  sodium  bicarbonate  the  least 
poisonous,  acetanilid  alone  next,  acetanilid,  caffeine,  and  sodium  bicar- 
bonate still  more,  and  acetanilid  and  caffeine  most. 

I  give  this  capsule,  if  the  attack  is  severe,  every  hour  for  four  doses, 
then  every  two  hours,  so  that  the  patient  gets  only  10  grains  (0.66  Gm.) 
in  ten  hours,  a  dose  set  down  in  some  of  the  books  as  a  single  dose,  though 
I  think  it  rather  large. 

In  the  vast  majority  of  cases  the  effects  are  very  manifest  in  terms  of 

1  Worth  Hale:  The  Effects  of  Caffeine  and  Sodium  Bicarbonate  upon  the 
Toxicity  of  Acetanilid.  The  Journal  of  Pharmacology  and  Experimental  Ther- 
apeutics, Vol.  I,  No.  2. 


220  TREATMENT  OF  ACUTE  INFECTIOUS  DISEASES 

relief  from  discomfort  within  a  very  few  doses  and  this  is  followed  soon 
by  a  fall  in  temperature,  which  is  usually  marked  by,  if  not  before,  the 
next  morning. 

If  such  relief  occurs,  one  may  give  the  capsule  the  next  day  at  three 
hour  intervals  and  the  next  at  four-hour  intervals.  In  the  lighter  attacks 
the  drug  need  not  be  continued  beyond  the  next  day.  If  the  attack  is 
prolonged  or  complications  ensue,  the  drug  should  not  be  too  long 
continued.  Such  continued  usage  will  do  harm.  Its  benefit  is  confined 
to  the  early,  sthenic  period  of  the  infection. 

This  is  very  important  to  remember,  for  one  must  not  entertain 
the  idea  for  a  moment  that  these  drugs  cure  the  disease  or  have  any 
direct  action  on  the  invading  organism.  They  simply  make  the  patient 
more  comfortable  and  in  better  condition  to  meet  the  infection. 

The  effects  of  these  drugs  on  fever  is  rather  interesting,  and,  indeed, 
we  need  once  in  a  while  to  orientate  ourselves  with  reference  to  our 
ideas  of  fever. 

Fever,  after  all,  is  a  state  or  condition  in  which  the  bodily  processes 
operate  at  a  higher  bodily  temperature.  This  state  may  be  variously 
brought  about;  but  here,  as  in  most  of  the  fevers  in  which  we  are  inter- 
ested, it  is  brought  about  by  the  action  of  the  toxins  of  the  infecting 
organisms  on  the  heat  regulating  mechanism.  We  often  speak  of  the 
patient  as  "burning  up  with  fever"  and  entertain  the  idea  that  his 
combustion,  his  oxidation  processes,  are  greatly  increased. 

This  is  not  the  case.  The  actual  increase  in  oxidation  ]p  slight.  While 
varying  in  different  diseases  and  individuals,  the  amount  of  increase  will 
not  average  over  25  per  cent,  of  the  heat  production  at  rest  and  as  com- 
pared with  the  output  of  heat  during  active  exercise  is  a  mere  bagatelle. 

A  man  at  rest  with  food  eliminated  812  grams  of  carbon  dioxide  in  the 
day  and  a  man  at  severe  work  3,073  grams  of  carbon  dioxide:  over  three 
and  a  half  times  as  much,  and  yet  all  the  heat  this  oxidation  represents 
induced  no  fever. 

Nor,  on  the  other  hand,  is  the  output  of  heat  greatly  interfered  with 
to  account  for  fever. 

What  seems  actually  to  occur  is  that  the  heat  regulation  has  been 
set  at  a  higher  level,  runs  on  a  different  plane. 

But  on  this  plane  the  same  mechanism  for  retaining  heat  when  the 
body  temperature  is  lowered  and  the  same  mechanism  for  getting  rid  of 
heat  when  the  body  temperature  is  raised  is  called  into  action  as  when 
running  at  a  normal  level.  At  this  new  level,  however,  the  mechanism  is 
not  so  nicely  adjusted  and  greater  variations  follow  from  lesser  influences 
exerted  on  it;  hence,  the  marked  effect  of  antipyretics  in  fever  that  we  do 
not  see  follow  in  conditions  of  health. 


GRIP  221 

This  regulating  mechanism  is  vested  in  special  nerve-tissue  some- 
where at  the  base  of  the  cerebrum,  in  the  neighborhood  of  the  corpus 
striatum. 

How  antipyretics  act  on  this  centre  we  do  not  know,  but  what  they  do 
is  to  knock  the  regulation  down  to  a  lower  level,  on  which  the  mechan- 
isms of  defense  against  an  increase  or  decrease  of  heat  are  called  into 
action,  just  as  on  the  higher  plane  before  the  administration  of  the  drug 
and  as  on  the  lower  plane  in  health. 

But  as  the  influence  of  the  drug  wears  off  or  the  influence  of  the  toxin 
reasserts  itself,  the  heat  regulation  is  pitched  higher  and  higher  to  its 
old  level. 

We  know  that  the  fever  is  not  the  disease,  only  a  symptom. 

We  know  that  temperature  above  102°  F.  is  accompanied  by  increased 
protein  destruction,  which  it  may  or  may  not  be  desirable  to  interfere 
with. 

We  know  that  the  temperature  may  become  so  high  as  to  threaten 
life  itself  and  then  certainly  should  be  combated;  but  we  are  coming 
more  and  more  to  scrutinize  symptoms  so  as  to  detect  in  them  expres- 
sions of  compensatory  processes. 

That  fever  was  a  favorable  state  in  the  presence  of  the  toxemia  of 
infection  was  an  idea  long  entertained,  more  lately  fell  into  disrepute 
and,  now,  most  recently,  is  being  advocated  by  thoughtful  men  and  care- 
ful observers. 

What  our  antipyretics  do  of  value  in  grip  is  probably  less  attributable 
to  the  lowering  of  temperature  than  to  the  relief  of  aches,  pains,  cerebral 
excitement,  all  of  which  mean  wear  and  tear,  and  so,  as  I  have  said,  make 
the  patient  better  able  to  cope  with  the  infection. 

Acetanilid  is  chemically  a  very  simple  body. 

It  is  derived  from  anilin,  CeHsNH^.  It  was  discovered  that  anilin 
had  the  property  of  lowering  temperature  but  that  it  was  at  the  same 
time  very  toxic,  inducing  collapse. 

I  have  shown  how  the  toxicity  of  a  drug  may  be  altered  by  the  intro- 
duction of  simple  radicles  into  its  constitution  without  altering  its 
efficiency  from  a  therapeutic  standpoint,  when  discussing  the  salicylates 
in  the  treatment  of  rheumatism.1 

Now  the  introduction  of  an  alkyl  radicle  to  replace  an  H  of  an  amido 
group  retards  the  action  of  the  base,  so  when  the  acetic  acid  radicle 
CH3CO  takes  the  place  of  an  H  in  the  amido  group  of  anilin,  CeH5NH 
(CH3CO),  it  retards  the  action  of  the  active  portion  of  the  molecule 
which  is  anilin  when  it  is  set  free,  and  it  does  that  by  offering  resistance 
to  the  oxidative  processes  of  the  organism,  by  which  the  setting  free  of 
1  See  Treatment  of  Rheumatic  Fever,  Chap.  III. 


222 


TREATMENT  OF  ACUTE  INFECTIOUS  DISEASES 


the  anilin  occurs.  The  result  is  a  partial  detoxication  of  the  anilin. 
When  the  anilin  is  set  free  the  body  further  oxidizes  it  to  a  paramido- 
phenol,  which  is  anilin  with  an  OH  radicle  taking  the  place  of  the  H  hi 
the  ring  opposite  the  NH2  group,  the  para 'position.  This  oxidation 
further  detoxicates  the  substance  and  when  finally  it  becomes  paired 
with  sulphuric  acid  or  glycuronic  acid  the  detoxication  is  coinplete  and 
the  substance  is  so  eliminated  in  the  urine. 


H—  N—  H 

H—  N—  CH3CO 

H—  N—  H 

H—  N—  CH3CO 

1 

1 

1 

1 

C 

C 

C 

C 

/  \ 

/  \ 

/  \ 

/  \ 

HC    CH 

HC    CH 

HC    CH 

HC    CH 

1     1 

1     1 

1     1 

!    1 

HC    CH 

HC    CH 

HC     CH 

HC    CH 

\  / 

\  / 

\  / 

\  / 

C 

C 

C 

C 

H 

H 

1 

1 

OH 

OC2H5 

1 

2 

3 

4 

1.  Aniline. 

2.  Acetanilid  in  which  one  of  the  H  atoms  in  the  amido  group  has  been  re- 
placed by  the  alkyl  radicle,  CH3CO. 

3.  Paramidophenol,  in  which  an  H  atom  in  the  opposite  group  (para  posi- 
tion) has  been  replaced  by  an  OH  radicle. 

4.  Phenacetin,  in  which  the  H  atom  of  the  para  position  of  acetanilid  has 
been  replaced  by  an  oxyethyl  group 


When  the  chemists  appreciated  the  means  by  which  Nature  detoxi- 
cated  acetanilid,  they  seized  on  the  paramidophenol,  which  while  less 
poisonous  than  anilin  was  still  capable  of  inducing  symptoms  in  kind  and 
of  still  changing  hemoglobin  into  methemoglobin  like  the  mother  sub- 
stance and  rendered  it  less  toxic  by  introducing  an  ethyl  radicle  into  the 
OH  in  the  para  position  and  thus  produced  a  body  which  permitted  the 
paramidophenol  to  be  set  free  from  its  molecule  still  more  slowly  and 
therefore  was  less  toxic.  The  characteristic  action,  being  all  the  tune 
due  to  the  paramidophenol. 

This  body  is  known  as  acetphenetidin  (phenacetin)  CioHi2N02.  One 
sees  then  that  phenacetin  is  acetanilid  in  which  the  H  of  the  para  posi- 
tion is  replaced  by  an  oxyethyl  group. 

So  it  is  with  all  this  group  of  drugs.  They  all  owe  their  activity 
to  the  setting  free  of  the  paramidophenol,  but  then*  efficiency  and  safety 
to  a  nicety  of  balance  between  "fast  enough"  to  have  action  on  the  tissue 
and  "slow  enough"  not  to  poison  the  tissue. 


GRIP  223 

So  in  administering  these  drugs,  the  amounts  and  frequencies  with 
which  they  are  administered  make  a  great  difference  in  the  ultimate 
results. 

If  one  entertains  prejudices  against  acetanilid,  one  may  use  the  less 
toxic  acetphenetidin  (phenacetin)  in  its  place  in  such  a  prescription  as  I 
have  just  given  in  doses  of  gr.  ii  to  iiss.  (0.125-0.150  Gm.) ;  or  it  may  be 
used  alone,  as  the  necessity  for  the  use  of  the  other  constituents  in 
this  case  obtain  to  a  less  degree. 

Toxic  Effects.  If  these  antipyretics  be  used  injudiciously  in 
large  amounts  or  in  cases  of  idiosyncrasy  for  the  drug,  certain  untoward 
results  may  ensue.  They  are  the  onset  of  (1)  collapse,  (2)  cyanosis, 
(3)  a  group  of  lesser  disorders. 

(1)  The  collapse  may  come  on  abruptly  or  after  certain  premoni- 
tory symptoms.    It  is  more  likely  to  ensue  with  acetanilid  than  with  the 
others  and  with  antipyrin  more  commonly  than  with  acetphenetidin 
(phenacetin). 

The  patient  is  pale,  the  skin  cold  and  clammy,  the  pulse  rapid,  small 
and  sometimes  irregular,  the  pupils  slightly  dilated  and  the  patient  faint, 
apathetic  or  confused.  He  may  remain,  however,  perfectly  conscious. 
The  treatment  like  that  of  collapse  from  any  cause  is,  in  brief,  applica- 
tion of  heat  and  stimulation.  (See  Chapter  IX.) 

(2)  Cyanosis.     A  marked  degree  of  cyanosis  is  a   characteristic 
symptom  of  poisoning  by  these  drugs  and  is  most  marked  after  acetan- 
ilid, less  after  acetphenetidin  (phenacetin)  and  least  after  antipyrin. 

It  occurs  early  relative  to  the  more  dangerous  symptoms  and  it  is 
not  an  uncommon  experience  to  see  patients  who  use  this  class  of  drugs 
freely  for  headache  and  neuralgias,  especially  in  the  shape  of  some  of  the 
proprietary  remedies,  with  blue  lips  and  finger  nails,  though  not  con- 
scious of  further  distress. 

The  cyanosis  is  not  an  indication  of  respiratory  or  circulatory  em- 
barrassment, but  is  due  to  changes  in  the  coloring  matter  of  the  blood, 
to  the  formation  of  methemoglobin.  Of  course,  if  the  dose  is  sufficiently 
large,  dyspnoea  and  cardiac  failure  ensue. 

Sodium  bicarbonate  is  supposed  to  have  some  antidotal  effect.  It  may 
be  given  freely  in  dram  doses  at  hourly  intervals  for  several  doses. 

(3)  Among    the    lesser    disorders    that    occasionally    appear    are 
eruptions,    erythemata,    urticaria,     or    even    angioneurotic    edema. 
There  may  be  burning  of  throat  or  mouth,  nausea  or  vomiting, 
excessive    perspiration,    more   rarely   apathy   or    mental    confusion 
or  disturbances  of  hearing. 

The  eruptions  may  give  rise  to  a  diagnosis  of  scarlet  fever  or  measles. 
In  the  former  case  the  sudden  onset  and  other  symptoms  may  easily 


224  TREATMENT  OF  ACUTE  INFECTIOUS  DISEASES 

be  diagnosed  as  grip  and  the   coal-tar  preparations   given  in  treat- 
ment. 

With  the  appearance  of  the  eruption  one  might  attribute  it  to  the 
coal-tar  products.  Take  no  chances  in  the  matter.  Treat  it  as  scarlet 
fever  until  proven  to  the  contrary.  When  one  has  to  differentiate 
between  two  conditions,  one  of  which  is  common,  and  the  other  unusual, 
one  should  always  give  preference  to  the  former.  One  should  not  let  the 
possibility  of  a  shrewd  diagnosis  run  away  with  sober  sense. 

By  enumerating  all  the  things  that  may  occur  after  the  use  of  the 
coal  tars,  I  do  not  wish  it  inf erred  that  they  are  common.  They  are 
really  safe  drugs  to  use,  when  used  properly.  More  cannot  be  said 
of  any  drug. 

As  has  been  said,  there  are  no  end  of  drugs  advised  for  grip.  When 
there  is  no  specific  for  a  disease,  one  is  impressed  with  this  or  that  line  of 
treatment  in  proportion  to  his  knowledge  of  the  man  who  advocates  it 
and  the  terms  in  which  he  estimates  it. 

Burney  Yeo,  whose  position  as  a  clinician  needs  no  comment,  in 
his  Manual  of  Medical  Treatment,  is  so  thoroughly  convinced  from  his 
personal  experience  of  the  efficacy  of  quinine  after  two  or  three  days 
preliminary  treatment  with  such  measures  as  I  have  described,  his  own 
preference  being  salicin,  that  I  cannot  refrain  from  mentioning  it  though 
I  have  had  no  personal  experience  with  it. 

He  uses  it  in  doses  of  gr.  i  to  iii  (0.060-0.20  Gm.)  every  three  to  four 
hours  and  prefers  to  give  it  in  solution  in  citric  acid;  lemon  juice  would 
answer. 

Certainly  the  doses  are  neither  large  nor  frequent;  the  effect  of  quinine 
upon  temperature  and  pain  and  to  lessen  metabolism  and  its  freedom 
from  bad  effects  are  well  known  and  would  lead  to  no  hesitation  in  its 
usage. 

Tracheitis.  Some  involvement  of  the  upper  air  passages  or  of 
the  trachea  is  almost  constant.  In  most  cases  it  is  slight  and  relief  is 
afforded  by  local  measures  or  by  inhalations.  Tracheitis  is  not  un- 
common, causing  a  nagging  cough,  and  a  feeling  of  rawness  or  discomfort 
under  the  sternum. 

I  am  fond  of  a  simple  remedy  that  works  admirably  in  many  instances. 
A  mixture  of  equal  parts  of  oil  of  turpentine,  spirits  of  cam- 
phor and  olive  oil  is  made,  a  bit  of  flannel  to  cover  the  anterior 
chest  is  saturated  with  it  and  laid  upon  the  chest,  pinned  into  the  night 
shirt  and  left  on  for  the  night.  This  may  be  made  in  the  house.  Order 
a  tablespoonful  of  each,  stir  with  the  spoon  and  saturate  the  cloth.  The 
patients  inhale  the  fumes  all  night  and  marked  relief  to  the  feeling  of 
soreness  and  tightness  is  afforded,  the  cough  ameliorated  and  ex- 


GRIP  225 

pectoration  facilitated.  Camphorated  oil  may  be  used  in  the  same 
way. 

Inhalations  of  compound  tincture  of  benzoin,  or  of  the  oil  of 
pine,  a  teaspoonful  or  two  on  a  pitcher  of  hot  water,  or  a  teaspoonful  to 
a  pint  in  an  inhaler,  or  a  few  drops  of  the  saturated  alcoholic  solu- 
tion of  menthol  on  a  pitcher  of  water  will  prove  grateful. 

If  the  cough  is  more  harassing,  codeine  phosphate  may  be  used 
in  doses  of  gr.  1/8  to  1/4  (0.008-0.015  Gm.)  every  two,  three  or  four 
hours,  or  heroine  hydrochloride  (diacetyl  morphine  hydrochloride)  in 
doses  of  gr.  1/10  to  1/12  (0.006-0.015  Gm.)  at  the  same  intervals. 

One  of  the  most  striking  characteristics  of  this  disease  is  the  weakness 
and  prostration  of  the  patient  after  even  a  short  course.  In  many, 
complications  of  a  mental  nature  bespeak  the  profound  effect  of  the 
poisons  on  the  nerve  centres. 

Convalescence  should  not  be  hurried.  Exposure  after  the  at- 
tack has  subsided,  although  a  matter  of  two  or  three  days  is  an  invi- 
tation to  relapse  or  complication.  The  danger  must  be  explained  to 
the  patient  and  the  demands  of  his  body  for  further  rest,  as  dictated 
by  his  weakness,  be  listened  to,  rather  than  his  mental  protests  and 
ambitions  and  business  urgencies.  If  the  patient  will  assume  this  atti- 
tude towards  himself ,  his  returning  strength  will  give  the  word  for  further 
indulgence. 

In  the  meantime  the  diet  should  be  made  liberal  to  make  good 
the  ravages  of  the  toxins.  Simple  well-cooked  foods,  solid  or  fluid,  are 
indicated.  Light  rubs  or  massage  given  to  the  sore  and  tired 
muscles,  fresh  air  and  plenty  of  it,  in  bed  or  chair  at  first  and 
later  in  the  walks  and,  if  the  convalescence  is  unduly  protracted,  a  change 
of  air  does  wonders. 

Patients  should  not  get  back  to  work  until  they  feel  again  the  impulse 
of  health.  At  this  juncture  tonics  are  supposed  to  be  indicated.  I 
believe  one  should  feel  that  the  best  tonics  are  to  be  found  in  fresh  air 
sunlight,  good  food  and  properly  proportioned  rest  and  exercise  rather 
than  in  drugs. 

If  our  patients,  however,  are  not  content,  after  such  measures  have 
been  honestly  adopted,  we  may  try  strychnine  sulphate  in  doses 
of  gr.  1/40  to  1/30  (0.0015-0.002  Gm.)  three  or  four  times  a  day  or  tinc- 
ture of  nux  vomica  in  equivalent  dosage  may  be  substituted. 

COMPLICATIONS 

Such  is  the  treatment  of  a  moderately  severe  attack  of  grip  with- 
out complications;  but  it  is  the  complications  that  makes  grip  the  serious 
disease  it  is. 


226          TREATMENT  OF  ACUTE  INFECTIOUS  DISEASES 

I  have  said  that  it  is  one  of  the  most  protean  of  diseases  we  have 
to  deal  with. 

What  organ  may  be  implicated  we  do  not  know,  but  there  are  a 
certain  number  so  frequently  involved  that  we  should  never  cease  to 
keep  our  eyes  open  for  the  first  indications  of  such  an  occurrence. 

The  respiratory  tract  in  some  part  of  its  extent  is  almost  certain 
to  be  implicated. 

Otitis  Media.  We  have  just  dwelt  on  the  lesser  manifestations 
of  grip.  Dependent  on  infection  of  the  upper  air  tract  is  the  common 
occurrence  of  otitis  media.  I  cannot  dwell  on  all  the  phases  of  this 
important  chapter  of  grip.  What  I  want  to  emphasize  is  the  vital 
importance  of  ever  keeping  it  in  mind.  In  older  patients  the  involve- 
ment of  the  ear  is  accompanied  by  pain,  so  that  it  is  not  likely  to  be  over- 
looked, but  in  children  and  especially  in  younger  children  this  does  not 
hold  true.  It  is  the  most  common  experience  of  a  pediatrist  to  find  the 
first  evidence  of  an  otitis  in  the  discharge  that  has  taken  place  through 
the  ruptured  drum. 

In  the  acute  infectious  diseases  of  childhood  it  is  good  practice  to 
examine  the  ears  periodically  and  in  such  diseases  as  scarlet  fever  and 
influenza  its  neglect  is  scarcely  pardonable.  Examination  of  the  child's 
ear  is  not  the  easiest  procedure  in  the  world  and  so  is  commonly  neglected 
by  the  general  practitioner,  but  routine  use  brings  its  reward  in  facility 
acquired. 

When  treating  a  young  child  or  infant  for  influenza,  suspect  the  ear 
if  there  is  a  sudden  exacerbation  of  temperature,  often  very  high  in 
children,  or  if  there  is  a  rise  of  temperature  after  the  normal  has  been 
reached,  or  the  child  becomes  much  sicker  without  obvious  cause  for  the 
manifestations.  The  temperature  of  otitis  in  children  may  be  long 
continued  and  sometimes  with  marked  excursions. 

Let  me  intercalate  here  that  when  I  see  long  continued  temperature 
in  children  with  marked  daily  excursions,  I  always  think  of  influenza, 
otitis  media  or  Bacillus-coli  infection  and  of  course,  in  a  malarial  dis- 
trict, of  malaria. 

The  incident  of  otitis  seems  to  vary  from  epidemic  to  epidemic  and 
its  virulency  too. 

That  mastoiditis  is  all  too  frequent  a  sequel,  that  sinus  throm- 
bosis and  meningitis  may  be,  that  some  of  the  cases  are  fulminating 
should  make  us  appreciate  the  seriousness  of  it,  and  seek  special  advice. 
If  this  is  not  at  hand  a  paracentesis  or  incision  is  simple  and  should 
not  wait  on  temporary  measures  of  relief. 

Pneumonia.  Another  result  of  infection  of  the  respiratory  tract, 
much  dreaded  and  constantly  to  be  watched  for  is  pneumonia.  In- 


GRIP  227 

fluenza  pneumonia  has  a  high  mortality,  which  differs  in  different  epi- 
demics. 

While  lobar  pneumonia  may  occur  with  grip  and  run  a  regular  course, 
the  typical  pneumonia  is  a  broncho-pneumonia.  As  a  rule  this  occurs  a 
few  days  after  the  onset  though  it  may  be  earlier. 

Grip  pneumonia  is  prone  to  be  insidious.  It  occurs  in  scattered 
foci;  it  is  often  incomplete,  its  physical  signs  are  very  irregular,  the 
subjective  symptoms  are  out  of  all  proportion  to  the  objective.  It  is 
frequently  slow  in  resolution. 

It  is  because  of  all  these  facts  that  the  lungs  should  be  examined 
daily.  In  two  classes  of  patients  the  search  should  be  especially  assid- 
uous; in  old  people  and  in  children.  In  old  people  the  signs  of  broncho- 
pneumonia  are  the  least  satisfactory.  They  may  be  absent  entirely 
and  the  diagnosis  be  made  on  the  degree  of  respiratory  embarrassment 
and  intoxication.  The  cough  may  or  may  not  be  prominent.  The 
temperature  may  not  be  elevated. 

The  signs  may  be  only  those  of  localized  bronchitis;  that  is,  rales, 
or  there  may  be  only  a  little  dulness  and  diminished  breathing.  One 
cannot  watch  the  chests  of  old  people  confined  to  bed  too  closely.  They 
are  extremely  susceptible  to  pneumonic  processes,  made  much  more  so 
in  a  grip  attack. 

In  children,  too,  it  must  be  remembered  that  the  physical  signs  are 
often  slight  and  that  the  diagnosis  may  have  to  be  made  on  the  rapidity 
of  respiration,  prostration  or  cough. 

The  irregularity  of  distribution  of  the  lesion,  the  incompleteness 
of  the  consolidation  and  the  persistency  of  signs  may  give  rise  to  the 
diagnosis  of  tuberculosis.  Such  a  case  in  a  young  man,  with  consolida- 
tion at  the  left  apex,  a  fairly  high  temperature  with  a  good  deal  of  excur- 
sion, a  severe  cough  and  a  prolonged  course  I  saw  diagnosed  as  a  case  of 
acute  miliary  tuberculosis  to  the  great  distress  and  alarm  of  the  family, 
in  which  tuberculosis  had  occurred. 

Again,  the  retardation  in  resolution  of  these  patchy  and  incomplete 
consolidations  may  occasion  the  same  diagnosis. 

When  these  cases  are  determined,  they  should  be  treated  as  pneu- 
monia arising  from  other  causes.1 

Tonsilitis,  bronchitis  and  pleurisy  are  to  be  treated  in  the 
same  manner  as  if  arising  under  other  conditions. 

Of  rhinitis  I  would  add  a  word. 

This  is  exceedingly  common  in  influenza.  It  is  often  very  distressing 
and  accompanied  by  much  frontal  headache.  This  usually  means  an 
involvement  of  the  sinuses. 

1  See  Treatment  of  Pneumonia,  Chap.  IX, 


228  TREATMENT  OF  ACUTE  INFECTIOUS  DISEASES 

When  the  frontal  sinuses  are  involved  there  is  pain  especially 
over  the  inner  third  of  the  orbtial  ridge  and  this  pain  is  made  worse 
by  blowing  the  nose;  when  the  ethmoidal  sinuses  are  involved  the  pain 
is  said  to  be  deeper  set  or  even  occipital;  when  the  antrum  is  involved 
there  is  pain  in  the  superior  maxillary,  especially  in  the  malar  region  and 
often  a  toothache  on  the  affected  side.  Our  efforts  should  be  to  endeavor 
to  shrink  the  mucous  membranes  enough  to  open  the  ducts  and  passages 
to  these  sinuses  to  allow  a  drain.  This  may  be  done  by  spraying  the 
mucous  membrane  with  adrenalin  1  to  10,000  and  after  the  drug  has 
exerted  its  effect  spray  with  an  oily  solution.  I  like  one  advised  by 
Coakley — namely : 

3 

Menthol gr.  xxx  (2 .  Gm.) 

Camphor gr.  xx  (1 . 30  Gm.) 

Eucalyptol m.  xx  (1 . 30  c.c.) 

Olei  Rosae m.  iii  (0.20  c.c.) 

Benzoinol,  q.  s.  ad 5  •  ii  (60 .  c.c.) 

M.  et  S.    Use  in  an  oil  atomizer. 

If  the  antrum  is  involved,  the  head  should  be  turned  to  the  sound 
side,  hanging  a  little  over  the  edge  of  a  pillow  to  facilitate  the  discharge. 

The  menthol  solution  as  so  given  I  find  at  times  too  strong.  It  may 
be  reduced  x  or  xv  grains  (0.60-1  Gm.)  or  the  whole  may  be  diluted 
with  more  benzoinol. 

If  the  nasal  discharge  is  marked,  order  extract  of  belladonna,  gr.  1/8 
(0.008  Gm.),  or  atropine  sulphate,  gr.  1/120  (0.0005  Gm.)  every  2  hours, 
until  the  discharge  stops  and  then  give  at  intervals  of  four  to  six  hours  to 
control  it. 

When  giving  belladonna  so  frequently,  one  should  not  forget  that 
many  people  have  an  idiosyncrasy  for  it  and  should  recall  the  early 
signs  of  accumulation,  pupils  widely  dilated  with  blurred  vision,  ery- 
thematous  eruption,  scarlatiniform  in  character,  excessive  dryness  of 
the  mouth,  and  rarely  a  talkative  delirium. 

I  have  seen  these  coryzas  outlast  the  attack  until  one  despaired  of  ever 
giving  relief  and  then  clear  up  in  forty-eight  hours  after  chang- 
ing to  a  new  locality. 

Of  course  one  must  be  assured  that  there  is  not  a  suppurative  process 
in  one  of  the  sinuses. 

I  might  add  that  some  of  the  cases  run  over  into  a  chronic  bronchitis 
or  that  small  abscess  cavities  form  or  bronchiectatic  cavities  and  that 
a  patient  may  become  a  veritable  bacillus  carrier. 

The  nervous  system  shows  the  effect  of  the  toxemia  in  no  inconsider- 
able number  of  the  cases. 


GRIP  229 

Neuritis  may  occur  as  after  any  infectious  disease  and  occasionally 
a  true  meningitis;  but,  as  strikingly  frequent,  follow  neuralgias. 
Marked  mental  depression,  which  all  too  often  becomes  melan- 
cholia, or  other  psychoses  make  their  appearance.  These  must  be  dealt 
with  as  under  other  circumstances. 

In  children  one  may  see  symptoms  of  meningitis  which  are  more 
commonly  due  to  a  meningismus  or  serous  inflammation  rather 
than  to  the  presence  of  the  influenza  bacillus  or  other  pyogenic  organism. 

In  such  a  case  a  lumbar  puncture  should  be  done;  first,  that  by 
examination  of  the  fluid  we  may  determine  the  presence  or  absence 
of  the  organism,  whether  it  is  purulent  or  not,  that  is,  whether  we  have 
to  deal  with  a  purulent  or  serous  meningitis;  and  second,  because  such  a 
procedure  often  brings  prompt  amelioration  of  the  symptoms.  I  have 
seen  nothing  more  striking  than  the  improvement  following  this  proce- 
dure. (For  technique  of  lumbar  puncture,  see  Cerebro-Spinal  Meningi- 
tis, Chap.  XXV.) 

I  would  emphasize  two  facts  borne  in  upon  me  by  my  children's 
service  at  Bellevue  Hospital;  first,  that  this  condition  of  meningismus, 
under  which  I  include  cases  of  serous  meningitis,  is  extremely  common 
in  many  acute  infections  and  also  in  gastro-intestinal  disturbances  and 
second,  that  the  differentiation  from  a  suppurative  meningitis  is  in  a 
large  percentage  of  these  cases  possible  only  by  a  lumbar  puncture,  a 
procedure  followed  by  more  fruitful  results  than  any  other  measure  of 
clinical  diagnosis  with  which  I  am  familiar. 

Prolonged  Fever.  In  some  cases  the  fever  drags  out  to  un- 
usual lengths.  This  is  seen  at  times  in  children.  They  should  be  put  in 
the  fresh  air  as  much  as  possible  and  their  nourishment  properly  con- 
sidered. 

It  is  more  than  doubtful  if  any  drugs  have  influence  on  this  prolonged 
intoxication.  When  all  other  measures  have  failed  there  is  one  that  has 
results  so  striking  and  on  the  whole  so  reliable  that  it  needs  an  emphasis, 
namely,  change  of  air. 

This  is  more  easily  attained  with  children,  with  whom  transporta- 
tion is  a  relatively  easy  problem. 

Moreover,  a  removal  to  a  remote  quarter,  to  an  entirely  different 
climate,  is  not  necessary. 

Equally  good  results  I  have  seen  by  sending  cases  to  places  no  farther 
removed  from  New  York  than  Atlantic  City,  Lakewood  or  Greenwich, 
nor  have  I  been  able  to  determine  that  the  woods  or  the  shore  offered 
any  peculiar  advantage  the  one  over  the  other.  I  have  seen  a  child  sent 
to  Lakewood  after  running  a  temperature  for  weeks  with  prompt  sub- 
sidence of  symptoms,  only  to  relapse  on  a  return  home,  to  as  promptly 


230  TREATMENT  OF  ACUTE  INFECTIOUS  DISEASES 

subside  again  after  a  second  trip  to  Lakewood.  There  a  longer  residence 
effected  the  cure.  These  prolonged  cases  in  children  associated  as  they 
often  are  with  a  cough  and  a  slight  bronchitis  not  infrequently  arouse  the 
fear  of  incipient  tuberculosis.  ., 

PROPHYLAXIS 

Were  the  mortality  of  influenza  as  high  as  that  of  tuberculosis  or  of 
pneumonia  or  were  the  mortality  directly  traceable  to  the  infection 
as  in  the  case  of  typhoid,  no  doubt  we  should  more  fully  appreciate 
the  importance  of  prophylaxis  and  urge  its  carrying  out,  but  we  do 
not  look  upon  influenza  as  a  highly  dangerous  disease  and  we  do  not 
attribute  the  deaths  from  pneumonia  to  the  Influenza  infection  with 
sufficient  emphasis,  so  little  precaution  is  taken  to  protect  the  individual 
or  the  community. 

There  are  three  ways  in  which  the  disease  is  especially  spread,  first 
by  those  who  are  a  little  ill,  are  suffering  from  a  " common  cold"  and 
move  about  among  their  fellows,  infecting  as  they  go;  second,  by  the 
very  ill  who  infect  other  members  of  the  family  or  attendants  because 
knowledge  of  the  mode  of  transmission  is  not  known  and  precautions  are 
not  insisted  upon  by  the  attending  physician ;  and  third,  by  the  carriers 
of  the  bacilli,  people  with  a  chronic  cough,  sufferers  from  chronic  bron- 
chitis, bronchiectasis  or  abscess. 

Lord  found  the  organism  of  Pfeiffer  present  in  25  to  59  per  cent, 
of  unselected  cases  of  chronic  cough  and  expectoration  in  interepidemic 
periods. 

With  the  first  class  of  cases,  patients  should  be  instructed  as  to  the 
meaning  of  " common  colds"  that  occur  in  epidemics,  how  easily  their 
cough,  with  its  spray  of  infecting  organisms,  can  pass  on  the  disease 
of  perhaps  fatal  severity  to  those  in  contact  with  them;  that  coughing 
and  sneezing  should  be  done  into  a  handkerchief,  that  sputum  should 
be  destroyed  and  that  intimate  contact,  kissing,  etc.,  should  be  sed- 
uously  avoided. 

Perhaps  no  more  certain  source  of  infection  exists  than  the  com- 
mon carriers. 

How,  wedged  into  a  car  or  train,  in  the  hours  of  crowded  traffic,  with 
sneezing  and  coughing  all  about,  with  insufficient  ventilation  or  such 
a  one  as  constitutes  a  draught  to  blow  over  the  heated  skin,  could  one 
escape  infection?  So  far  as  possible  these  places  should  be  avoided 
during  an  epidemic. 

Of  the  second  class  of  cases,  the  family  should  be  instructed  that 
the  patient  is  a  source  of  infection  and  that  remaining  unnecessarily 


GRIP  231 

long  with  the  patient  increases  the  danger;  the  nurse  should  be  instructed 
to  see  that  the  secretions  are  received  into  proper  receptacles,  vessels 
provided  with  5  per  cent,  carbolic  a'cid,  or  into  cloths  that  should  be 
burned;  that  the  cloths  in  contact  with  the  patient  should  be  sterilized 
by  boiling,  that  his  utensils  and  thermometer  be  kept  separate  and 
that  after  he  has  convalesced,  the  room  should  be  fumigated  with  for- 
malin. 

With  reference  to  the  third  class  of  cases,  more  difficulty  exists  until 
the  health  authorities  make  more  inquiry  into  the  nature  of  chronic 
processes  and  take  measures  for  the  public  protection. 

SUMMARY 

Rest. 
Bed.    Half  bed  of  iron  of  hospital  type  preferred  in  severely  ill. 

Room. 

Light  and  air. 

When  the  attack  is  trivial  the  patient  should  be  advised  to  remain 
in  the  house  and  assured  of  a  shorter  course  if  he  goes  to  bed. 

Onset. 

Chill. 

Hot  drinks,  water,  tea,  lemonade,  whiskey  or  brandy. 
Hot  water  bags  to  feet,  blankets. 

Fever. 

Sponge  bath  with  tepid  water. 
Alcohol  rub. 
Cold  cloths  to  head. 
Cracked  ice  to  suck. 

Bowels. 

Saline  cathartic. 

Seidlitz  powders,  liquor  magnesii  citratis  5viii-xii  (240-360  c.c.) 
Rochelle  or  Epsom  or  Glauber's  salt  5ss.-i  (15-30  Gm.)  or  begin 
with  Calomel  (Hydrargyri  chloridum  mite),  gr.  %  (0.015  Gm.) 
every  quarter  hour  for  six  doses. 
Follow  in  three  to  four  hours  by  saline. 

Diet. 

No  food  at  onset.  Later  milk,  eggs,  cereals,  gruels,  toast,  broths, 
mutton  or  chicken,  thickened  with  rice,  barley  or  other  flour  or 
cereal. 

In  prolonged  complicated  cases  consider  caloric  needs. 

(See  Chaps.  II  and  XIV.) 


232  TREATMENT  OF  ACUTE  INFECTIOUS  DISEASES 

Symptomatic  treatment. 
Sthenic  period  of  toxemia. 
Drugs. 
Antipyretics. 

Acetanitid,  antipyrin,  phenacetin  (acetphenetidin). 
Acetanilid. 

In  small  doses  frequently  repeated,  either  alone  gr.  iss.-ii  (0.10- 
0.15  Gm.)  or  in  combination.    For  example. 

I* 

Acetanilidi 1 . 50         gr.  xxiiss. 

Sodii  Bicarbonatis 1 . 00         gr.  xv 

Caffeinae Citratae 0.50         gr.  viiss. 

M.  et  divide  in  capsulas  no.  xv. 

S.    One  every  hour  for  four  doses,  then  every  two  hours. 

As  improvement  occurs  make  the  dose  every  three  hours  and  every 

four  hours. 
Phenacetin. 

May  be  given  alone  in  doses  of  gr.  ii-iiss.  (0.125-0.16  Gm.)  or  in 

combination  with  sodium  bicarbonate  and  caffeine  as  above. 
Give  at  same  intervals  as  the  acetanilid. 
Antipyrin. 

May  use  like  acetanilid  and  phenacetin. 
Dose  when  frequently  repeated  gr.  ii-iiss.  (0.125-0.16  Gm.). 
Salicylates. 

Especially  aspirin  in  capsules,  gr.  v  (0.30  Gm.)  every  two  hours. 
Quinine  in  capsules,  gr.  i-iii  (0.060-0.20  Gm.)  or  in  solution  in 
citric  acid,  gr.  x  (0.60  Gm.)  in  lemon  juice,  every  three  or  four 
hours  after  two  or  three  days   of  preliminary   treatment  with 
salicin,  e.  g.,  gr.  v- viiss.  (0.30-0.50  Gm.)  (Yeo). 
Or  this  may  follow  two  or  three  days  of  acetanilid,  phenacetin  or 
antipyrin  treatment,  outlined  above. 

Tracheitis. 

Apply  to  anterior  chest,  over  sternal  region  flannel  saturated  with 
Oil  of  turpentine, 
Spirits  of  camphor, 
Olive  oil,   equal   parts;  leave   on   all  night;  or   camphorated   oil 

applied  in  the  same  way. 
Inhalations. 
Steam  from  croup  kettle,  pitcher  of  hot  water  with  paper  cone, 

or  from  some  simple  inhaler.    Pour  on  to  this  hot  water  3i-ii  (4- 

8  c.c.)  -of  compound  tincture  of  benzoin,  or  oil  of  pine  or  oil  of 

eucalyptus. 
Inhale  as  often  or  as  long  as  it  is  grateful.    Pour  on  to  the  hot  water 

a  few  drops  of  a  saturated  alcoholic  solution  of  menthol  and 

inhale. 


GRIP  233 

Cough. 

Codeine  phosphate  in  solution  gr.  1/8-gr.  1/4  (0.008-0.015  Gm.)  to 
5i  (4  c.c.)  of  water  every  four,  three  or  two  hours  according  to 
severity;  or  codeine  sulphate  in  tablets  in  same  dose. 

Or  heroine  hydrochloride  (diacetyl  morphine  hydrochloride),  gr.  1/12- 
1/10  (0.005-0.006  Gm.)  at  same  intervals. 

Convalescence. 

Care  to  avoid  exposure  to  inclement  weather  conditions  or  to  undue 
exertion  or  fatigue  immediately  after  an  attack,  even  when  mild, 
lest  a  recrudescence  or  complication  like  severe  bronchitis  or 
pneumonia  ensue. 

Diet. 

Should  be  made  more  liberal. 
Fresh  air. 

Massage. 
Tonics. 

Strychnine  sulphate,  gr.  1/40-gr.  1/30  (0.0015-0.002  Gm.)  or  tincture 
of  nux  vomica  m.  x-xv  (0.60-1  c.c.)  three  or  four  times  a  day. 

Complications. 

Otitis  media. 
In  children,  ears  should  be  examined  every  day,  regardless  of 

symptoms  referable  to  ear. 

(The  magnifying  electric  otoscope  greatly  facilitates  these  ex- 
aminations for  the  general  practitioner.) 
When  the  drum  is  inflamed  and  bulging,  incise  the  drum  (para- 

centesis  or  myringotomy). 

If  in  doubt  about  the  indication  for  the  procedure,  incise. 
Pneumonia. 

Examine  the  lungs  daily  and  with  especial  care  in  the  aged  and 

feeble. 

Treat  as  under  other  circumstances. 
(See  Pneumonia,  Chap.  IX.) 
Tonsillitis,  Bronchitis  and  Pleurisy.     (See  Chaps.  V,  VII  and  VIII.) 

Treat  as  under  other  circumstances. 
Rhinitis. 

Treat  as  under  other  circumstances. 
Sinusitis. 

Spray  the  nose  with  a  cleansing  solution,  2  per  cent,  boric  acid 

solution. 
Quarter  to  half  strength  DobeU's  solution,  or  one  of  the  numerous 

equivalents  on  the  market.    This  to  clear  the  mucous  surfaces 

of  secretions. 
Follow  with  adrenalin  hydrochloride  (epinephrin)  spray  1-10,000 

or  stronger   (1-5,000,    1-2,000)    or  use  any  other  epinephrin 

solution. 


234  TREATMENT  OF  ACUTE  INFECTIOUS  DISEASES 

(This  to  shrink  the  mucous  membrane  and  open  the  sinuses.) 
Follow  this  with  sprays  to  prolong  the  effect  of  the  adrenalin, 

e.  g., 

Menthol 7 gr.  xxx    2.00 

Camphor gr.    xx    1 . 30 

Eucalyptol m.  xx     1 .30 

(or  one  can  use  1  per  cent,  of  each) 

Olei  rosse  (may  be  omitted) m.  iii      0.20 

Benzoinol  q.  s.  ad gii         60.00 

M.  et.  S.    Use  oil  atomizer. 

If  antrum  is  involved,  turn  to  sound  side  and  hang  head  off  edge 
of  pillow  to  facilitate  discharge. 

Extract  of  belladonna  leaves,  gr.  1/8  (0.008  Gm.) 

or 

Atropine  sulphate,  gr.  1/120  (0.0005  Gm.)  every  six  to  four  hours. 
Persistent  rhinitis. 

Change  of  locality. 
Mental  depression. 

Requires  watchfulness,  as  true  melancholia  with  its  self-destruc- 
tive impulses  may  follow. 
Meningeal  manifestations. 

(See  text.) 
Prolonged  Fever. 

When  not  due  to  complications  will  often  yield  to  change  of  locality. 

Prophylaxis. 

Instruction  in  the  meaning  of  "  common  colds,"  their  infectivity  and 

the  condition  they  may  give  rise  to  in  another. 
Avoidance  of  too  close  contact  with  those  suffering  from  "  colds." 
Danger  of  coughing,  sneezing  and  kissing  during  attacks  of  "colds." 
Danger  in  crowded  cars  and  crowds  during  epidemics. 
Destruction  of  secretions  from  those  suffering  from  Grip. 
Avoidance  of  close  contact  with  Grip  patients. 
Knowledge  that  individuals  suffering  from  chronic  cough  are  in  a 

large  per  cent,  of  cases  " carriers"  of  the  influenza  bacillus. 


CHAPTER  XII 

EPIDEMIC  INFLUENZA 

ONE  who  has  seen  the  great  pandemics  of  1889-90  and  1918  are  im- 
pressed with  two  facts:  First  that  there  are  striking  differences  in  the 
clinical  pictures  afforded  by  epidemic  cases  of  influenza  and  the  sporadic 
cases  that  we  have  been  accustomed  to  label  influenza.  For  this  reason 
I  have  deemed  it  well  to  retain  in  this  book  the  chapter  on  Grip  in  which 
these  sporadic  cases  were  included  and  to  write  a  new  chapter  on  Epi- 
demic Influenza.  The  second  striking  fact  is  that  there  were  many 
considerable  differences  in  the  features,  course,  complications  and  se- 
quelae between  these  two  great  epidemics  or  pandemics  and  similar 
great  differences  between  the  pandemic  of  1918  and  the  recurrence  later. 

The  clinical  and  pathological  differences  naturally  gave  rise  to  a 
question  as  to  the  identity  of  the  microorganisms  responsible  for  these 
different  forms.  The  influenza  bacillus  of  Pfeiffer  had  not  yet  been  dis- 
covered in  1889  and  its  identity  in  sporadic  cases  in  1892  lead  to  the 
assumption  that  it  was  responsible  for  the  epidemic  of  1889-90. 

When  the  epidemic  of  1918,  having  ravished  Europe,  reached  these 
shores  it  assumed  a  malignancy  that  led  many  to  believe  it  was  due  to 
some  unknown  viruB  and  that  the  presence  of  influenza  bacilli  were 
accidental  or  incidental,  but  with  increasing  reports  from  both  Army  and 
civil  workers  and  with  improving  technique  the  presence  of  the  bacillus 
influenza?  was  found  to  be  so  constant  and  the  experimental  work  on 
monkeys  infected  with  the  organism  by  such  workers  as  Blake  and  Cecil 
so  exactly  reproduced  the  pulmonary  lesions  as  seen  in  man,  that  the 
Pfeiffer  bacillus  has  come  to  be  pretty  generally  accepted  as  the  etiological 
agent  of  epidemic  influenza.  However,  pneumococci  and  streptococci 
and  to  some  extent  staphylococci  have  been  so  constant  invaders  that  it 
is  difficult  to  analyze  the  parts  played  by  each  in  the  character  of  the 
attack,  the  pathologic  response  and  the  mortality  of  the  disease. 

Pathology.  Owing  to  differences  in  terminology  and  the  diffi- 
culties of  word  picturing,  it  is  not  easy  to  visualize  the  lesions  in  the 
lung  that  are  characteristic  for  the  influenza  organism  as  given  in  the 
literature;  moreover,  with  the  usual  invasion  by  pneumococci  and 
streptococci  this  is  further  obscured. 

The  influenza  infection  attacked  peculiarly  the  upper  air  passages, 
the  trachea,  bronchi  and  lungs.  The  trachea  and  bronchi  were  intensely 


236  TREATMENT  OF  ACUTE  INFECTIOUS  DISEASES 

congested  and  the  cough  commonly  harassing  and  of  a  tracheal  type. 
The  nasal  mucous  membrane,  pharynx,  tonsils  and  accessory  sinuses 
might  be  involved  as  well,  but  the  escape  of  these  structures  from  any 
serious  inplieations  struck  me  as  rather  remarkable. 

The  walls  of  the  bronchi  were  found  in  many  cases  to  be  penetrated 
by  the  influenza  bacillus  and  the  walls  weakened  to  the  production  of 
bronchiectasis. 

In  my  earlier  1918  experiences  at  Bellevue  Hospital  this  epidemic 
fell  upon  us  with  all  the  horrors  of  a  medieval  plague  and  in  spite  of  all 
the  advantages  that  modern  medicine  had  brought  to  assist  us  in  the 
fight,  I  again  and  again  felt  the  sense  of  overwhelming  helplessness  and 
almost  despair  that  our  medical  forefathers  must  have  experienced.  At 
this  time  the  pathology  of  the  lung  explained  the  high  mortality,  the 
fruitless  struggle,  and  has  been  well  described  by  Symmers.  It  was  a 
hemorrhagic  type  of  broncho-pneumonia;  both  lower  lobes  massive  with 
exudate;  their  surfaces  purple  or  slate-blue  and  mottled,  little  or  no 
fibrin  on  the  pleurae;  cut  surfaces  smooth  and  free  from  fibrin,  exuding 
blood-stained  exudate  of  serum,  and  red  and  white  cells.  This  was  a 
confluent  type  of  lobular  pneumonia  and  interspersed  with  areas  of 
emphysema,  often  standing  out  like  small  bubbles  or  beads  on  the  surface 
of  the  pleurae.  This  emphysema  was  striking  on  the  edge  of  the  lung. 
The  upper  lobes  were  less  involved,  with  consolidation  in  their  lower 
parts,  while  the  upper  portions  were  very  emphysematous.  Many  of  the 
lungs  showed  a  broncho-pneumonia  as  defined  by  Delafield  and  called  by 
McCallum  "  Interstitial  Broncho-Pneumonia."  The  process  begins  in 
the  walls  of  the  bronchioles  and  spreads  to  the  air  vesicles  surrounding  it. 
It  is  an  infiltration  of  mononuclear  cells  about  the  walls  of  the  bronchi 
and  walls  of  the  alveoli  and  about  the  vessels.  The  walls  become  thick- 
ened, there  is  some  exudate  in  the  bronchioles  and  alveoli.  Organization 
begins  early.  It  is  distinctly  a  productive  process.  Some  cases  showed 
a  mixed  type  of  lobar  and  lobular  pneumonia.  Some  showed  a  pure 
lobar  pneumonia  as  might  be  expected  from  the  frequent  presence  of 
pneumococci.  These  were  mostly  of  Type  IV.  Streptococci  were  more 
commonly  found  in  the  broncho-pneumonia  cases,  though  the  broncho- 
pneumonia  may  be  provoked  by  pneumococci  or  influenza  bacilli  may  be 
found  in  pure  culture. 

After  the  initial  epidemic  had  quieted  down  and  later  lighted  up  again, 
its  characteristics  changed  in  many  particulars;  this  was  true  of  the 
pathological  changes  in  the  lung.  The  lungs  were  not  so  early  involved ; 
the  pleura  was  involved  in  the  majority  of  cases  and,  in  a  large  percentage 
of  these,  effusions  were  of  a  semi-purulent  or  frankly  purulent  nature. 
Small  pleural  and  subpleural  abscesses  were  very  common,  as  well  as 


EPIDEMIC  INFLUENZA  237 

abscesses  in  the  substance  of  the  lung  and  purulent  infiltrations  in  the 
interlobar  and  intralobular  septa  or  succulated  empyemata;  the  lungs 
instead  of  showing  the  confluent  hemorrhagic  and  exudative  lobular 
pneumonia  of  the  early  epidemic,  offered  the  most  extraordinary  variety 
of  lesions  (Symmers). 

Symptomatology.  It  seems  to  me  as  I  hark  back  on  that  epi- 
demic, as  if  every  case,  touched  by  the  hand  of  Death,  sped  to  its  fatal 
issue;  but  the  truth  is  all  degrees  of  severity  were  met  with. 

The  incubation  period  was  short,  from  one  to  three  or  four 
days;  the  onset  abrupt,  the  progress  uninterrupted  throughout  the 
course;  or  it  began  like  a  trivial  cold  or  febrile  attack,  which  subsided 
after  a  day  or  two  and  then  tempted  the  patient  to  go  out  and  resume 
work,  whereon  he  promptly  came  down  with  a  recrudescence  of  his 
infection  and  a  pneumonia.  It  became  my  custom  to  emphatically  warn 
against  regarding  these  lesser  attacks  as  trivial  and  to  urge  the  patient  to 
remain  in  the  house  or  even  in  bed  for  some  time  longer;  and  yet  I  saw 
cases  who  obeyed  these  instructions  implicitly  suffer  the  same  sequence 
of  events. 

The  attack  may  be  very  light,  then,  or  on  the  other  hand  fulminating, 
the  patients  stricken  from  the  start  so  overwhelmingly  that,  as  Symmers 
said,  some  were  thought  actually  to  be  cases  of  gas  poisoning  and  tested 
for  evidences  of  such.  These  cases  were  prostrated,  deeply  cyanotic, 
became  comatose  and  died  and  showed  at  autopsy  great  dilatation  of  all 
the  capillaries  and  a  heart  immensely  dilated  on  its  right  side,  inducing 
failure  of  that  organ.  One  feature  that  struck  me  in  some  of  these 
cases  was  their  parched  appearance.  It  seems  as  if  their  tissues  were 
dessicated  and  they  went  on  to  the  end  often  without  manifesting  a 
single  physical  sign  referable  to  any  part  of  the  respiratory  tract. 

In  the  majority  of  cases,  however,  the  symptoms  were  those  of  a 
severe  grip  attack  with  especial  involvement  of  the  trachea  and  larger 
bronchi;  but  with  certain  features  quite  peculiar  to  itself. 

With  the  sudden  onset,  preceded  by  nothing  more  than  at  times  a 
chilliness,  came  headache,  boring  pain  in  the  eye-balls,  injected  conjunc- 
tive, backache  and  pain  in  the  •  extremities.  In  the  severe  types  low 
muttering  or  active  delirium  may  obtain.  Insomnia  may  be  present.  At 
times  one  sees  the  picture  of  meningismus  and  we  saw  in  the  early  cases 
of  the  epidemic  profound  mental  depression;  it  being  difficult  to  elicit 
any  response  from  a  perfectly  conscious  patient;  even  melancholia  and 
dementia  were  reported  in  rare  instances.  If  the  respiratory  tree  was 
affected,  the  tracheitis  was  the  most  harassing  feature,  the  cough  elic- 
ited by  it  being  constant,  violent  and  well-nigh  uncontrollable.  Coryza 
and  sore  throats,  while  reported,  were  in  my  experience  rare,  except  in 


238  TREATMENT  OF  ACUTE  INFECTIOUS  DISEASES 

the  slight  attacks  mentioned  above.  Indeed,  the  escape  of  the  nose  and 
throat  seemed  to  me  very  striking. 

But  as  more  characteristic  than  the  symptoms  cited  above  were  the 
following:  first,  prostration  out  of  proportion  to  other  symptoms; 
second,  cyanosis,  early  and  out  of  all  proportion  to  evidences  of  circula- 
tory failure.  It  affected  the  lips,  fingers,  ears,  mucous  membranes  and 
the  skin  of  the  face  and  neck  and  chest,  corresponding  fairly  to  the 
blushing  area.  The  effect  was  that  of  duskiness,  a  red  overlaid  with  a 
light  stroke  of  blue,  sometimes  so  deep  as  to  suggest  coal-tar  poisoning 
from  acetanilid  or  phenacetin.  This  occurred  even  in  cases  with  no  pul- 
monary complications.  Erythema  in  this  same  area  was  common, 
mingled  to  a  greater  or  less  degree  with  the  cyanosis.  One  th^ng  that 
struck  me  in  the  epidemic  was  the  puffy  condition  of  the  tissues  that 
seemed  almost  like  air  cushions,  even  if  there  was  no  crackling  as  in  the 
case  of  the  occasional  emphysema  of  the  subcutaneous  tissues. 
Epistaxis  was  not  uncommon,  in  some  series  amounting  to  10  per 
cent.;  and  this  tendency  to  hemorrhage  was  further  seen  in  the  oc- 
casional vomiting  of  blood  and  bloody  diarrhea,  petechiae  in  the  mucous 
membranes,  and  where  the  lung  was  involved,  very  bloody  sputum 
occurred  in  many  cases.  Menstruation  seemed  to  be  precipitated  by 
the  attack. 

The  temperature  rises  abruptly  to  102°  F.  to  105  F.  and  may  fall  as 
rapidly  in  36  to  48  hours,  or  it  rises  again  after  one  to  three  days,  usually 
as  an  expression  of  pulmonary  involvement.  More  commonly  it  falls 
by  lysis  in  the  course  of  two  to  seven  days,  averaging  five. 

The  slow  pulse,  100  or  under,  that  accompanied  the  high  fever  and  the 
highly  toxic  state  was  one  of  the  most  striking  features  of  the  disease.  It 
gave  an  erroneous  impression  of  the  real  state  of  the  circulation  and  often 
led  to  a  neglect  of  circulatory  needs.  Even  when  pneumonia  set  in,  the 
pulse  is  relatively  slow  and  a  convalescence  often  shows  a  striking 
bradycardia.  The  pulse  may  accelerate,  however,  and  particularly 
near  a  fatal  end. 

Respiration,  like  the  pulse,  was  curiously  moderate  in  rate,  even 
with  serious  pulmonary  involvement,  though  this  was  not  universally 
the  case. 

As  striking  as  the  slow  pulse,  was  the  blood  reaction.  This  was  a  frank 
leucopenia  or  one  that  remained  at  normal.  It  is  as  striking  as  in  ty- 
phoid fever.  If  a  leucocytosis  does  occur,  complications  should  be 
suspected. 

Retention  of  urine  was  not  uncommon  and  had  to  be  kept  in  mind  by 
the  attendant.  Profuse  sweating  might  occur  and  I  have  seen  one 
patient  with  a  general  sudamina,  an  erythema  followed  by  desqua- 


EPIDEMIC  INFLUENZA  239 

mation  and  the  separation  of  casts  of  the  feet  as  complete  as  ever  seen  in 
scarlet  fever,  which  presented  a  classical  picture  of  the  old  English 
Sweating  Sickness  that  is  looked  upon  by  some  epidemiologists  as  an 
expression  of  influenza  (Crookshank). 

When  pneumonia  develops  all  symptoms  are  intensified.  So  con- 
stantly did  pneumonia  develop  that  it  seemed  to  me  that  it  was  less  a 
complication  than  an  integral  part  of  the  infection  and  that  when  it  did 
not  obtain  one  might  call  the  case  an  abortive  one.  It  might  come  on  in 
the  very  beginning  as  in  the  fulminating  cases,  or  later.  It  was  a  common 
experience  to  see  the  initial  temperature  fall  in  one  to  three  days,  then 
rise  again  as  evidence  of  spread  to  the  lungs.  If  the  fever  was  maintained 
at  the  end  of  six  days  it  was  practically  certain  that  pneumonia  was 
present,  however  scant  or  deceptive  the  physical  signs.  Cyanosis 
deepened,  the  patient  looked  septic,  stupor  increased,  the  respiration 
accelerated,  but  by  no  means  constantly,  the  pulse  usually  remained 
slow  until  towards  the  end,  the  sputum  became  bloody,  the  blood  count 
might  increase  depending  on  the  character  of  the  secondarily  invading 
organisms  or  complications. 

Death  in  my  experience  was  more  commonly  due  to  the  onset  of  pul- 
monary edema  than  from  any  other  cause. 

This  is  not  the  place  to  discuss  physical  signs,  which  present  a  great 
variety  of  findings;  but  I  will  say  briefly  that  I  found  more  constantly 
than  any  other  a  diminished  breathing  at  both  bases,  earlier  and  more 
marked  on  one  side,  with  a  few  rales  and  hyperresonance  elsewhere  in 
the  lungs.  The  scattered  areas  of  emphysema  in  the  consolidated  lung 
at  first  obscured  the  usual  dulness  of  a  consolidation,  but  this  increased 
later  to  all  degrees.  Bronchial  voice  and  breathing  were  far  from  con- 
stant, but  were  often  met  with,  indistinct  or  classically  shrill. 

Treatment.  No  stone  was  left  unturned  to  support  and  afford 
relief  to  these  patients  and  it  was  just  because  there  was  no  specific 
treatment  that  measures  multiplied  without  limit  and  it  is  hard  to  pass 
judgment,  amid  the  encomiums  and  condemnations,  as  to  the  value  of 
most  of  these.  Again  it  is  doubtful  if  we  shall  ever  see  a  repetition  of 
events  as  we  witnessed  it  during  the  pandemic  of  1918,  for  it  differed  in 
many  respects  from  that  of  1889-90  and  changed  very  materially  in  the 
recrudescences  that  came  in  the  years  following  the  1918  pandemic. 
For  that  reason  one  feels  himself  rather  in  the  attitude  of  an  historian 
than  a  guide. 

Isolation.  Every  case  should  be  isolated.  During  an  epidemic 
an  infection  that  commonly  would  be  designated  as  a  cold,  coryza,  sore 
throat  should  be  suspected  and  isolated.  The  infection  must  be  pro- 
mulgated through  the  secretions  of  the  mouth  and  nose,  by  sneezing, 


240  TREATMENT  OF  ACUTE  INFECTIOUS  DISEASES 

coughing,  kissing,  even  by  conversation  at  close  range,  by  handkerchief, 
eating  utensils,  towels  in  common  use,  etc.,  and  all  members  of  a  house- 
hold should  be  made  to  understand  how  each  may  be  a  source  of  danger 
to  the  other  and  how  best  that  danger  may  be  avoided.  It  is  most  diffi- 
cult to  impress  on  the  victim  of  a  common  cold  during  an  epidemic  that 
if  he  goes  about  his  usual  duties  as  he  has  been  accustomed  to  under 
ordinary  conditions,  that  he  is  multiplying  his  chances  of  a  pneumonia, 
should  this  "common  cold"  be  of  influenza  origin;  lessening  his  chances 
of  recovery  and  imperilling  all  with  whom  he  comes  in  contact.  How 
many  times  during  this  epidemic  has  Cassandra  and  her  discredited 
prophecies  come  to  my  mind. 

Room.  This  should  be  chosen  with  reference  to  good  ventil- 
ation and  light  and  adjacent  to  a  bath  room.  It  should  be  stripped  of  all 
superfluous  furnishings,  everything  being  sacrificed  to  facility  in  han- 
dling the  patient  and  convenience  of  the  nurse  and  physician. 

No  members  of  the  family  other  than  those  in  attendance  on  the 
patient  should  be  admitted.  The  air  should  be  kept  fresh  and  tempera- 
ture between  60°  F.  to  65°  F.  Some  patients  find  a  colder  air  more 
grateful;  others  suffer  from  an  aggravation  of  their  cough  unless  it  is 
warmer. 

In  the  hospital  a  cubical  system  should  be  adopted.  The  patients 
should  be  separated  by  efficient  screens  or  sheets.  It  seems  criminal  to 
permit  one  patient  who  may  be  suffering  from  a  streptococcus  pneumonia 
to  cough  in  the  face  of  another  patient  across  a  short  space  between  the 
beds.  Moreover,  it  prevents  the  patients  from  handling  the  objects 
within  reach  that  belong  to  their  next-door  neighbor  that  may  carry 
secondary  infection.  In  the  wards,  too,  dry  sweeping  should  be  for- 
bidden, but  floors  had  better  be  scrubbed  with  water  containing  com- 
pound solution  of  cresol  or  some  other  antiseptic. 

Bed.  The  best  bed  is  the  hospital  type,  a  single  bed  or  at 
most  a  three-quarter  bed  with  woven  wire  springs  and  a  firm  mattress. 
The  double  bed  makes  the  task  of  the  nurse  very  great  and  interferes 
with  proper  examinations  by  the  physician.  Broken  springs,  uneven 
mattresses  and  feather  beds  add  discomforts  for  the  patient.  The  woven 
wire  spiing  is  covered  with  a  blanket  to  make  the  surface  smooth,  over 
this  is  placed  a  rubber  sheet,  extending  from  the  bend  of  the  knees  to 
the  pillow,  over  this  a  sheet  drawn  smooth  and  over  this  a  draw  sheet 
consisting  of  a  long  sheet  doubled  and  laid  across  the  bed,  the  excess  of 
length  tucked  under  one  side  to  be  gradually  drawn  from  tune  to  time 
to  the  other  side,  affording  a  cooling  effect  to  the  patient's  back  or  to 
remove  damp  or  soiled  spots.  The  upper  sheet  and  blankets  as  light  as 
compatible  with  warmth  complete  the  bed.  The  bed  should  be  remade 


EPIDEMIC  INFLUENZA  241 

each  day  and  refreshed  at  night.  Care  must  be  taken  to  avoid  wrinkles 
and  crumbs  of  food  remaining  in  the  bed.  To  turn  the  mattress  with 
the  patient  in  bed,  an  extra  mattress  is  needed.  The  patient  and  mat- 
tress are  half  drawn  off  the  bed,  the  patient  is  rolled  over  on  the  extra 
mattress  and  this  pulled  into  place.  All  the  accessories  are  now  added, 
by  rolling  patient  on  his  side,  wrinkling  the  sheet  lengthwise,  tucking 
under  one  side  and  smoothing  half  across  the  bed,  then  rolling  the 
patient  back  on  the  smoothed  sheet  and  drawing  the  rest  of  the  rolled 
sheet  smooth  to  the  other  side.  Pillows  should  be  fairly  firm,  but  not 
hard.  A  Gatch  bed  is  excellent  if  it  can  be  secured,  as  it  affords  a  good 
bed  rest  in  convalescence.  (See  index.) 

Physician.  The  physician  should  protect  himself  by  using  a 
gauze  mask  while  visiting  the  patient.  If  he  is  susceptible,  the  coughing 
of  the  patient  in  the  course  of  an  examination,  often  directly  into  his  face 
as  the  throat  is  being  inspected,  in  spite  of  the  patient's  effort  to  refrain, 
make  infection  almost  inevitable  without  some  such  device.  If  he  is 
immune  he  may  still  become  a  carrier  and  imperil  the  next  patient  he 
sees.  The  mask  may  be  made  of  squares  of  a  few  thicknesses  of  gauze 
large  enough  to  cover  mouth  and  nose  with  a  good  margin  to  spare,  to  the 
four  corners  of  which  tapes  are  attached  to  tie  behind  the  head.  He 
may  take  several  of  these  starting  on  his  rounds.  Each  mask  is  left  after 
a  visit  to  be  destroyed  by  fire.  At  the  end  of  his  visit  he  should  cleanse 
his  hands  thoroughly  with  soap  and  hot  water  which  will  probably  be 
efficient  or  he  may  further  disinfect  them  with  alcohol,  bichloride,  car- 
bolic or  lysol.  As  regards  spraying  the  throat  and  nose  I  have  my  doubts 
about  the  value  of  the  measure.  The  secretions  have  themselves  pro- 
tective powers  and  the  trauma  done  the  mucous  membrane  by  harsh 
solutions  and  the  spray  nozzles  may  open  the  way  to  infections. 

So  far  as  possible  he  should  see  other  patients  than  those  suffering 
from  influenza  at  the  beginning  of  the  day  and  on  the  slightest  evidence 
of  a  "  cold  "  on  his  part,  he  should  desist  from  his  visits  and  make  himself 
a  patient ;  less  perhaps  for  his  own  sake  than  for  the  danger  he  entails  to 
others,  if  this  cold  should  turn  out  to  be  influenza.  I  am  well  aware  that 
such  precautions  cannot  in  many  instances  be  regarded ;  but  where  they 
can  they  should  be. 

The  Nurse.  She  should  so  far  as  possible  protect  herself.  The 
constant  intimate  contact  with  the  patient  makes  precaution  on  her  part 
even  more  imperative  than  on  that  of  the  physician.  The  mask  should 
be  used,  frequently  changed  and  burned.  A  gown  may  well  be  worn, 
especially  if  the  exigencies  of  the  household  make  some  contact  with 
other  members  of  the  family  necessary.  Her  hands  should  be  frequently 
cleansed,  especially  after  handling  the  patient's  secretions,  feeding  the 


242  TREATMENT  OF  ACUTE  INFECTIOUS  DISEASES 

patient,  handling  his  dishes  and  before  her  own  meals,  when  using  a 
handkerchief  and  on  going  off  duty.  The  nails  should  be  cut  close  and 
a  nailbrush  used.  One  must  doubt  the  efficacy  of  all  these  measures, 
however,  when  he  considers  the  multitude  of  .opportunities  for  infection 
in  the  long  and  close  contact  of  nurse  and  patient.  However,  it  is  only 
just  that  she  should  know  what  may  be  done  to  lessen  these  chances. 
She  should  have  sufficient  time  off  for  rest  and  exercise  in  the  open 
air.  She  should  have  her  meals  with  some  degree  of  regularity  and  give 
proper  attention  to  the  condition  of  her  bowels.  Two  nurses  are  needed 
on  very  sick  cases  or  at  least  relief  by  the  most  competent  member  of  the 
household.  If  nurses  cannot  be  gotten  the  doctor  must  give  explicit 
instructions  to  the  substitute  and  warn  her  in  what  way  she  may  become 
a  source  of  peril  to  the  other  members  of  the  family. 

Warnings  to  Other  Members  of  the  Family.  Keep  away  from 
patient  unless  needed  to  be  of  assistance,  and  then  do  not  kiss  or  expose 
oneself  to  the  cough.  Avoid  contact  with  articles  handled  by 
the  patient.  Always  cover  the  nose  and  mouth  when  sneezing  or 
coughing. 

Any  member  showing  symptoms  that  might  be  interpreted  as  a 
beginning  infection  should  be  isolated  at  once.  Prophylactic  sprays  and 
gargles  do  not  appeal  to  me,  but  Sailer's  observations  of  the  relatively 
good  result  that  seemed  to  follow  sprays  of  2  per  cent,  quinine  sulphate 
as  compared  with  others  may  be  worth  trying.  Enough  aromatic  sul- 
phuric acid  is  added  to  put  the  sulphate  in  solution. 

Each  nostril  is  sprayed  15  seconds  and  the  throat  30  seconds  night  and 
morning. 

Care  of  Patient.  The  maximum  of  rest  is  to  be  achieved  by 
quiet,  a  comfortable  bed,  good  nursing,  a  well-ventilated  room  and 
combating  insomnia.  A  cleansing  bath  of  warm  water  and  castile  soap 
should  be  given  daily,  the  skin  gently  dabbed  dry  and  a  sterile  toilet 
powder  applied.  Points  of  pressure  in  stuporous  or  comatose  patients 
should  receive  special  care,  with  gentle  rubbing  and  massage  and  alcohol 
rubs. 

Mouth.  The  mouth  should  be  kept  clean  by  gargle  and  sprays 
of  simple  salt  solutions,  Y^  strength  or  full  strength  (4  per  cent.)  boric 
acid  solution  or  DobelTs  solution  }/%  to  %  strength. 

The  teeth  should  be  gently  brushed,  using  a  simple  dentifrice  and  the 
interstices  of  the  teeth  cleared  of  food  particles. 

If  the  patient  is  very  ill  and  sordes  collect  on  teeth,  lips  and  tongue  one 
may  soften  with  y%  strength  of  a  solution  of  hydrogen  dioxide  and  scrape 
the  tongue  with  the  edge  of  a  whale-bone.  Application  of  a  solution 
containing 


EPIDEMIC  INFLUENZA  243 

Phenol  1  in  20  (watery  solution) 

Glycerin aagi  (  30  c.c.) 

Boric  acid,  saturated  watery  solution g  viii         (240  Gm.) 

may  be  grateful  and  is  antiseptic. 

The  nasal  mucous  membrane  may  be  much  congested  and  blocked 
and  should  be  kept  free  from  secretions.  This  may  be  done  by  softening 
dried  secretions  with  olive  oil  on  cotton,  using  a  wooden  tooth  pick  as  an 
applicator  and  then  spray  with  some  of  the  solutions  mentioned  above 
and  gently  cleanse  with  cotton  on  an  applicator.  Sprays  containing 
menthol  as  the  principal  ingredient  or  a  mentholated  vaseline  application 
may  be  found  desirable.  A  spray  of  1  per  cent,  menthol  and  oil  of 
eucalyptus  in  liquid  petrolatum  (albolene)  may  be  recommended,  or 
such  a  prescription  as  the  following:— 

Menthol gr.  xxx        (2  Gm.) 

Camphor gr.  xx          (1 .30  Gm.) 

Eucalyptol m.  xx          (1.30  c.c.) 

Olei  Rosae m.  iii          (0.20  c.c. 

Benzoinol,  q.  s.  ad 5  ii  (60.  c.c.) 

Met.  S.    Use  in  an  oil  atomizer  (Coakley). 

If  there  is  frontal  headache  or  much  turgescence  of  the  nasal  mucous 
membrane  use  adrenalin  chloride  (epinephrin)  dropped  in  full  strength 
(1 :1000)  or  diluted  in  normal  saline  or  Dobell's  solution  (l-A  or  1-8)  and 
follow  this  with  the  menthol  spray. 

Eyes  should  be  carefully  cleansed  with  warm  water  to  free  from 
secretions  and  if  the  conjunctivas  are  much  injected  one  may  use  boric 
acid  solution  diluted  one-half  or  full  strength,  dropped  into  the  eye 
or  cold  compresses  saturated  with  the  solution  may  be  laid  upon  the 
eyes. 

Especial  attention  should  be  paid  to  the  extremities  in  the  very  ill  and 
the  hot  water  bag  placed  at  the  feet  if  cold.  Secretions  from  the  nose 
and  mouth  should  be  received  on  pieces  of  gauze,  placed  in  a  paper  bag 
and  burned.  The  patient's  dishes  and  table  utensils  should  be  boiled 
after  using  and  bed  linen  that  has  been  soiled  should  be  put  at  once  in  a 
disinfectant  in  water  and  later  boiled,  at  least  10  minutes. 

Bowels.  The  bowels  should  be  opened  at  the  beginning  of  the 
illness.  In  children  castor  oil  may  be  given  or  citrate  of  magnesia. 
In  adults  castor  oil,  gss.-l  (15-30  c.c.)  or  salines  such  as  Epsom  or 
Rochelle  salt  in  gss.-i  (15-30  Gm.)  doses  or  less  drastic  salines,  such 
as  liquor  magnesii  citratis  gviii  (240  c.c.)  or  one  of  the  salines  on 
the  market  of  the  Hunyadi  water  type.  Later,  enemata  or  mild  salines 
are  indicated  if  the  bowels  fail  to  move  as  they  should  daily.  The  bed 


244  TREATMENT  OF  ACUTE  INFECTIOUS  DISEASES 

pan  must  be  insisted  on  in  all  very  ill  patients.  The  only  compromise 
if  the  patient  cannot  or  will  not  use  the  bed  pan  is  a  commode  at  the 
bedside  with  the  patient  well  protected.  Some  patients  who  cannot 
use  the  pan  or^  those  so  ill  as  to  make  the  use^of  the  bed  pan  onerous 
(for  it  is  certainly  fatiguing  to  some  patients)  should  be  encouraged  to 
let  the  bowels  move  into  large  quilted  pads  placed  under  them  t for  that 
purpose.  These  are  readily  folded  up  without  soiling  the  bed  and 
burned.  It  should  be  emphasized  that  purging  is  not  desirable  at 
any  stage,  but  an  assurance  of  an  unloaded  bowel  is. 

Diet.  It  should  consist  of  milk,  milk  preparations  and  milk  soups, 
milk  toast,  cereals,  bread,  eggs,  cream  soups  and  purges,  custards  and 
jellies,  orange  and  pineapple  juice,  stewed  fruits;  mutton  and  chicken 
broth,  cocoa;  milk  sugar  may  be  used  to  fortify  milk  or  drinks.  (See 
Typhoid  Fever,  Chap.  XIV.)  A  suitable  diet  may  be  selected  from  the 
list  given  under  typhoid  fever.  Food  should  not  be  pushed  during  the 
early  and  highly  toxic  period,  but  all  allowed  that  the  patient  is  inclined 
to  take.  In  the  prolonged  cases  and  those  with  a  slowly  resolving 
pneumonia,  the  caloric  needs  must  be  met  by  the  dietary  and  patients 
urged  to  approximate  3000  calories  or  more. 

Fluids.  It  has  been  my  custom  to  give  fluids  freely  and  in 
the  stuporous  patients  to  offer  drinks  at  frequent  intervals.  There  has 
been  some  inveighing  against  this  practice,  based  on  theoretical  condi- 
tions that  do  not  appeal  to  me.  Water,  alkaline  waters,  fruit  juices,  such 
as  lemonade  and  orangeade,  grape  juice  and  grape  fruit  juice  and  weak 
tea  are  permissible. 

Aches  and  pains  in  the  early  sthenic  stage  of  the  infection  may 
be  relieved  by  drugs  classed  as  antipyretics  and  coal  tars.  The  object  of 
their  administration  is  not  at  all  to  influence  the  fever,  but  to  relieve  the 
discomforts.  All  have  been  tried ;  the  various  salicylic  acid  combinations, 
quinine,  acetanilid  or  its  congeners,  separately  and  in  combination. 
Often  the  faith  in  some  one  such  prescription  seems  to  give  more  comfort 
to  the  practitioner  than  relief  to  the  patient.  However,  the  action  of  all 
members  of  these  groups  is  that  of  anodynes  and  their  early  usage  is 
legitimate.  Personally  I  prefer  to  use  small  doses  of  coal-tar  preparations 
frequently  repeated  rather  than  larger  doses  at  rarer  intervals;  choosing 
the  most  potent  of  the  group,  actanilid,  and  giving  it  in  doses  of  gr.  iss. 
(0.10  Gm.).  To  lessen  its  irritating  effect  on  the  stomach  and  for  what 
detoxicating  effect  it  may  have,  I  combine  it  with  small  doses  of  bicar- 
bonate of  soda  and  to  enhance  its  anodyne  action  add  citrated  caffeine. 
For  years  I  have  used  in  the  cases  of  sporadic  grip  the  following  pre- 
scription for  which  I  am  indebted  to  Dr.  Austin  Hollis  of  New  York 
City. 


EPIDEMIC  INFLUENZA  245 

Acetanilid gr.  iss.  (0 . 10  Gm.) 

Sod.  Bicarb gr.  i  (0.066  Gm.) 

Caffeine  Citrat gr.  ss.  (1 .033  Gm.) 

M. 

Such  a  dose  is  given  in  capsules  one  every  J/£  hour  for  four  doses,  then 
every  hour  for  four  doses,  then  every  two  hours. 

Small  doses  of  acetphenetidin  (phenacetin)  in  doses  of  gr.  iii  (0.20  Gm.) 
might  be  substituted  or  antipyrin  gr.  ii  (0.125  Gm.)  which  being  soluble 
will  allow  the  prescription  to  be  administered  as  a  fluid.  However, 
it  is  the  coal  tar  that  is  the  active  member  and  the  others  may  be  omitted. 

Of  the  salicylates  I  prefer  acetylsalicylic  acid  (aspirin)  in  gr.  v-x 
(0.33  to  0.66  Gm.)  doses  at  two-hour  intervals.  Some  men  combine  the 
acetanilid  and  acetylsalicylic  acid,  giving  gr.  iss.  (0.10  Gm.)  of  the 
former  and  gr.  ii  (0.130  Gm.)  of  the  latter. 

These  drugs,  all  of  which  are  more  or  less  depressant  to  the  circulation, 
should  not  be  used  except  in  the  early  period  of  the  infection. 

If  the  pain  is  considerable  and  unyielding  to  the  above  measures  and 
in  any  case  when  associated  with  any  asthenia,  codeine  and  morphine 
are  safer  and  more  effectual,  given  hypodermatically,  codeine  phosphate 
gr  .1/8-gr.  1/2  (0.008  to  0.030  Gm.)  and  morphine  sulphate  gr.  1/12  to 
gr.  1/4  (0.005  to  0.015  Gm.). 

Headache  may  be  relieved  by  cold  applied  to  the  head,  as  an 
ice  bag.  It  may  be  due  to  congestion  of  the  nasal  passages  and  be 
relieved  by  a  few  drops  of  adrenalin  (epinephrin)  to  either  nostril. 

Bullowa  puts  three  minims  of  adrenalin  (1-1000)  into  each  nostril  and 
3  minims  under  the  tongue  at  three-hour  intervals.  He,  like  some  others, 
conceives  it  to  be  absorbed  to  produce  general  effects.  If  this  is  so  it 
would  seem  to  me  to  be  an  excellent  measure;  but  our  own  observations 
on  the  administration  of  adrenalin  by  mouth  has  rendered  me  very 
sceptical  of  any  effect  it  may  have  on  the  circulatory  apparatus. 

Insomnia. — Loss  of  sleep  soon  fatigues  and  patients  with  con- 
tinued insomnia  do  not  do  well.  It  should  receive  immediate  attention 
and  not  be  allowed  to  go  on  night  after  night  without  interference. 
Again,  do  not  be  deceived  by  the  report  of  the  nurse  or  attendant  that 
the  patient  has  really  slept,  if  he  himself  complains,  for  quiet  does  not 
necessarily  mean  sleep  and  sleep  may  be  frequently  interrupted. 

If  the  patient  is  apprehensive  of  his  condition,  his  "nervousness"  may 
be  responsible  for  his  insomnia  and  bromides  may  be  given,  either 
potassium  bromide  or  the  mixed,  so-called  "triple"  bromides,  of  sodium, 
potassium  and  ammonium  in  equal  parts.  One  may  give  gr.  xv  (1  Gm.) 
in  three-quarters  of  a  glass  of  water  early  in  the  evening  and  repeat  two 
or  three  hours  later,  if  needed;  or  gr.  xxx  (2  Gm.)  may  be  given  at  once. 


246  TREATMENT  OF  ACUTE  INFECTIOUS  DISEASES 

If  this  is  not  effectual,  one  may  give  trional,  gr.  xv  (1  Gm.)  suspended 
in  a  warm  drink  or  dissolved  in  a  little  whiskey  or  wine  or  in  capsules  of 
gr.  v  (0.33  Gm.)  each  or  dry  as  powder  on  the  tongue  to  be  washed  down 
with  water.  This  dose  may  be  given  early  in  the  evening  and  repeated 
late  in  the  evening,  if  necessary.  If  it  is  effectual,  often  the  patient  will 
sleep  the  following  night  without  assistance.  If.  used  from  time-  to  time, 
small  doses  gr.  v  (0.33  Gm.)  may  prove  effectual.  Or  one  may  choose 
chloralamid  gr.  xx-xxx  (1.33-2  Gm.)  given  in  the  same  manner  except 
that  a  hot  menstruum  should  not  be  used,  as  it  decomposes  the  sub- 
stance. This  too,  may  be  repeated.  Adalin  gr.  v  (0.33  Gm.),  barbital 
(veronal)  gr.  v-viiss.  (0.33-0.50  Gm.)  or  sodium  barbital  (medinal)  in 
the  same  doses,  neither  of  which  latter  two  are  favorites  of  mine,  may 
be  used.  If  these  milder  methods  are  not  effectual  one  should  not  wait 
longer,  but  use  morphine  sulphate  hypodermatically  in  doses  of  gr.  J4 
(0.015  Gm.)  or  divide  the  dose  into  gr.  1/8  (0.008  Gm.)  to  repeat.  Co- 
deine phosphate  in  doses  of  gr.  J4  to  gr.  ss.  (0.015  to  0.030  Gm.)  might 
be  substituted.  Certain  patients  who  have  an  idiosyncracy  for  mor- 
phine bear  its  derivative  codeine  well. 

Delirium  or  psychoses,  developing  from  insomnia  or  exhaustion 
indicate  morphine  at  once.  A  mild  delirium  may  yield  to  hyoscine 
given  as  the  hydrobromide,  hypodermically  in  doses  of  gr.  1/200  to  gr. 
1  /150  (0.0003  to  0.00045  Gm.) .  One  should  not  forget  that  noise,  talking, 
visitors,  heat,  light,  stuffiness,  and  an  uncomfortable  bed  may  all  contrib- 
ute to  insomnia. 

Vomiting.  In  some  instances  this  is  an  early  symptom  and 
may  be  excessive.  Food  should  be  stopped,  a  mustard  paste  (one  part 
of  mustard  and  three  to  four  of  flour)  applied  to  the  pit  of  the  stomach 
and  cracked  ice  given  to  relieve  thirst.  Food  should  be  resumed  as  milk 
or  buttermilk  in  teaspoonful  doses,  at  frequent  intervals. 

Diarrhea  is  not  common  and  may  be  controlled  by  bismuth 
subnitrate  in  doses  of  gr.xv  to  5  i  (1-4  Gm.)  doses  at  two-hour  intervals. 

Circulation.  In  any  severe  case  it  is  well  to  digitalize  the  heart 
early.  This  will  be  discussed  under  the  next  section. 

Pneumonia.  Every  case  of  influenza  was  a  potential  pneumonia, 
which  in  nearly  all  severe  cases  became  actual.  The  pneumonic  process 
may  begin  at  once  and  was  not  infrequently  fulminating  in  character;  or 
the  progress  may  be  more  gradual,  delaying  commonly  to  the  fifth  or 
sixth  day.  Again  and  again  a  fall  of  temperature  in  a  day  or  two  after 
what  seemed  a  slight  attack  or  what  was  interpreted  as  a  "  common 
cold"  was  in  another  day  or  two  followed  by  a  rise  ushering  in  the 
pneumonic  process.  Indeed,  such  a  secondary  rise  nearly  always  means 
pneumonia.  As  1  have  said,  exposure  out  of  doors  after  the  initial  attack 


EPIDEMIC  INFLUENZA  247 

seemed  to  invite  the  recurrence;  though  recurrence  happened  even  with- 
out exposure.  Any  attack  in  which  the  temperature  remained  sustained 
to  the  fifth  and  sixth  day  practically  always  meant  pneumonia.  The 
absence  of  convincing  physical  signs  not  infrequently  lead  to  a  failure 
of  diagnosis. 

In  fulminating  cases  one  may  suspect  streptococcus  hemolyticus  or 
more  rarely  staphylococcus  aureus;  though  pneumococcus  is  not  neces- 
sarily excluded.  In  the  gradually  developing  type  pneumococci  are  more 
commonly  found,  though  streptococci  may  be  the  invaders.  In  every 
case  where  the  facilities  will  permit,  sputum  and  blood  should  be  cultured 
and  if  pneumococci  are  recovered,  they  should  be  typed.  If  Type  I  is 
established  serum  should  be  given  at  once. 

Pneumococcus  serum.  For  all  details  for  typing  and  administra- 
tion of  Type  I  serum  see  Pneumonia,  Chap.  IX. 

Symptomatology.  With  the  onset  of  pneumonia  the  symptoms 
detailed  above  are  intensified;  prostration  is  increased  and  cyanosis 
deepened.  The  pulse  and  respiration  may  be  accelerated;  but  both  may 
remain  comparatively  slow  until  near  the  end.  The  sputum  becomes 
blood  tinged,  often  the  patient  spits  almost  pure  blood  like  an  hemop- 
tysis. The  blood  count  may  be  increased  in  total  white  and  percentage 
of  polymorphonuclears,  but  this  may  be  wanting  or  at  least  be  far  less 
conspicuous  than  in  the  ordinary  forms. 

Circulation.  It  is  my  belief  that  in  every  acute  infectious  disease 
in  which  the  circulation  may  well  be  compromised  later  that  a  prophy- 
lactic administration  of  digitalis  is  indicated.  In  influenza  then,  unless 
the  attack  is  obviously  light,  where  even  the  suspicion  of  pneumonia 
occurs  and  in  all  severe  cases  of  influenza,  even  in  the  absence  of  any  signs 
of  pneumonia  it  was  my  custom  to  digitalize  the  heart.  One  should  give 
some  30  grains  of  digitalis  in  the  course  of  two  or  three  days;  or,  if  the 
case  is  severe,  inside  of  36  hours,  and  when  the  circulation  is  actually 
endangered  I  begin  with  intravenous  or  at  the  least  intramuscular  in- 
jections of  strophanthin3/4  to  1  mg.  (gr.  1/80-1/60)  and  follow  at  once 
by  digitalis.  It  may  be  necessary  to  give  far  more  than  30  grains  in  the 
end.  One  must  judge  by  the  effect.  It  is  to  be  administered  until  the 
pulse  is  slower  or  the  heart  sounds  better  or  the  evidences  of  impairment 
are  lessened  or  until  toxic  manifestations,  such  as  nausea  and  vomiting, 
bradycardia  and  cardiac  arythmia,  premature  systoles,  are  in  evidence. 

For  the  details  of  digitalis  medication  in  this  condition  see  Pneumonia, 
Chap.  IX  and  the  Summary. 

If  digitalis  has  been  sufficiently  administered  I  believe  that  other 
so-called  cardiac  stimulants,  such  as  camphor,  caffeine  and  strychinine, 
add  little;  but  I  am  far  from  decrying  the  usage  of  drugs  that  good  men 


248  TREATMENT  OF  ACUTE  INFECTIOUS  DISEASES 

have  recommended.  Dogmatism  is  obstructive.  What  I  wish  to  reite- 
rate again  and  yet  again  is  that  recourse  to  these  drugs  is  commonly  the 
result  of  ignorant  and  inefficient  use  of  the  digitalis  series.  Five  drops 
of  a  tincture  three  times  a  day  is  not  medication?:  it  is  nearer  murder. 

For  a  discussion  for  the  lesser  cardiac  stimulants  see  Pneumonia, 
Chap.  IX.  and  the  Summary. 

If  the  blood  pressure  is  very  low  as  in  a  certain  group  of  cases,  adren- 
alin (1-1000)  into  the  muscle  in  doses  of  m.  x-xv  (0.66-1  c.c.)  at  two, 
three  or  four  intervals  may  help,  or  it  may  be  given  well  diluted  in  saline 
and  slowly  into  the  vein,  but  the  total  dose  should  not  be  more  than 
m.  ii-iii  (0.120-0.20  c.c.)  at  least  the  first  time  and  the  result  noted  with 
the  sphygmonomanometer.  Pituitrin  in  1.  c.c.  doses  (m.  xv)  at  4-6  hour 
intervals  may  be  tried  as  well.  Sometimes  a  gentle  pressure  on  the 
abdomen,  for  example,  with  binder  and  pad  and  an  elevation  of  the  foot 
of  the  bed  may  be  helpful.  If  cyanosis  is  intense  and  skin  and  mucous 
membranes  are  congested  it  would  seem  logical  to  take  off  blood  from  the 
veins  and  the  more  as  we  are  told  by  competent  pathologists  (Symmers) 
that  such  cases  commonly  show  at  death  an  enormous  dilatation  of  the 
right  heart.  Such  cases  would  find  distinct  embarrassment  from  raising 
the  foot  of  the  bed ;  on  the  contrary  they  need  a  bed-rest.  If  the  patient 
is  conscious  the  position  in  which  he  finds  the  greatest  comfort  and 
least  respiratory  embarrassment  is  sure  to  be  the  proper  one  to  adopt. 
It  is  exceedingly  difficult  to  tell  how  much  good  these  measures  do.  The 
slow  pulse  gives  one  the  impression  of  a  good  circulation  and  many  men 
believe  the  heart  is  rarely  involved.  However,  my  own  experience  has 
been  that  edema  of  the  lungs  was  the  common  terminal  event  and 
while  I  am  unprepared  to  discuss  the  roles  of  circulatory  imbalance  and 
toxemia  exerted  on  pulmonary  capillaries  in  the  production  of  the  condi- 
tion, I  feel  fortified  to  a  degree  against  the  accident  if  1  have  pursued  the 
above  measures. 

Pulmonary  Edema.  However  difficult  it  may  be  to  judge  of  the 
result  of  our  measures  on  the  general  circulation,  the  rapid  change  that 
sometimes  follows  our  efforts  in  pulmonary  edema  is  a  little  more  con- 
vincing. The  routine  I  followed  in  these  cases  was  as  follows: 
1.  Strophanthin  given  intravenously.  Of  the  amorphous,  official 
strophanthin  1  mg  (gr.  1/60);  of  the  crystalline  strophanthin  of  Thorns 
or  Ouabain1  1/2  mg(gr.  1/120)  provided  the  patient  has  not  had  digitalis 
or  but  little.  If  digitalis  has  been  administered,  in  one-half  or  three- 
quarters  the  above  dose  cautiously.  This  may  be  repeated  in  four  hours, 
if  needed.  I  have  seen  brilliant  results  follow.  I  have  seen  recurring 

1  Strophanthin  in  above  doses  is  marketed  in  ampoules  containing  the  above 
dose  ready  for  hypodermic  or  intravenous  use. 


EPIDEMIC  INFLUENZA  249 

edemas  clear  up  after  repeated  doses  that  I  should  not  dare  to  advise. 
2.  Adrenalin  Chloride  (epinephrin) .  This  is  given  intramuscularly 
in  doses  of  m.  xv  (1  c.c.)  every  15  minutes  for  6  doses  if  necessary.  Ad- 
renalin is  used  if  the  strophanthin  has  not  been  successful  or  if  the  dosage 
of  digitalis  has  been  such  as  to  make  one  hesitate  to  use  the  strophanthin. 
I  have  seen  excellent  results  follow  this  measure.  3.  Atropine.  If 
these  measures  fail,  use  atropine  sulphate  gr.  1/100  (0.0006  Gm.)  intra- 
muscularly. This  dose  may  be  increased  to  gr.  1/75-1/50  (0.0009- 
0.0012  Gm.).  It  may  be  repeated  in  four  hours.  I  have  not  been  im- 
pressed with  atropine.  4.  Oxygen  inhalation.  This  I  believe  to  be 
a  useful  measure  in  embarrassment  of  respiration.  It  is  practically  useless 
as  commonly  administered  with  the  funnel  held  in  front  of  the  face. 
It  has  been  shown  that  the  inspired  air  gains  scarcely  2  per  cent,  by  this 
method.  During  the  epidemic  I  attached  a  skirt  or  broad  piece  of 
adhesive  plaster  to  the  funnel,  thus  making  a  mask.  The  free  surface  of 
the  plaster  was  prevented  from  sticking  by  an  opposing  piece  of  the 
adhesive.  One  may  use  for  the  same  purpose  oil  silk  attached  to  the 
funnel  by  adhesive.  This  roughly  covered  the  mouth  and  nose  and  must 
have  increased  considerably  the  content  of  the  oxygen  in  the  inspired 
air;  but  it  had  its  disadvantages;  it  was  clumsy  and  hot.  Better  yet  is 
the  method  used  in  treatment  of  some  of  the  gas  cases.  A  soft  rubber 
tube  is  inserted  in  one  nostril,  attached  by  a  little  adhesive.  In  this  way 
alveolar  oxygen  could  be  raised  to  over  20  per  cent,  and  if  the  opposite 
nostril  was  closed  rhythmically  with  each  inspiration  by  an  attendent,  the 
oxygen  in  the  expired  air  rises  to  about  60  per  cent.  (Rudolf).  Meltzer 
has  devised  an  apparatus  by  which  the  oxygen  in  the  expired  air  can  be 
made  to  rise  to  85  per  cent,  or  more.  It  may  be  administered  for  periods 
of  10  to  15  minutes  or  as  much  or  as  long  as  affords  the  patient  relief. 

Cupping.  Excellent  observers  have  been  convinced  of  the  value 
of  dry  cups  in  pulmonary  edema.  (For  technique,  see  Pneumonia, 
Chap.  IX.) 

My  objection  to  their  use  is  the  disturbance  in  turning  the  patient  to 
make  the  application  general.  I  have  twice  in  my  experience  noted 
a  pulmonary  edema  develop  under  my  stethoscope  as  a  result  of  turning 
the  patient  to  examine  him.  I  have  constantly  cautioned  my  students 
against  frequent  and  prolonged  examinations  in  pneumonia.  Indeed, 
I  make  it  a  rule  in  the  dangerously  ill,  in  whom  the  diagnosis  is  obvious, 
to  make  no  examination  of  the  back,  except  when  the  question  involves 
a  pleurisy  with  effusion  or  empyema. 

Cyanosis  and  Dyspnoea.  In  general  it  may  be  said  that  cyan- 
osis means  insufficient  oxygen,  anoxemia;  we  associate  it  with  an  inade- 
quate supply  of  oxygen  coming  to  the  blood  through  some  respiratory 


250  TREATMENT  OF  ACUTE  INFECTIOUS  DISEASES 

defect  or  to  slowing  of  the  circulation  through  cardiac  inefficiency, 
change  in  the  form  of  hemoglobin,  such  as  is  produced  by  the  toxic 
action  of  coal  tars,  notably  acetanilid,  which  produces  marked  cyanosis 
of  a  peculiar  hue.  •» 

In  influenza  the  cyanosis  is  striking  and  resembles  the  cyanosis  of 
acetanilid  poisoning  in  its  hue  and  in  its  dissociation  from  respiratory  or 
cardiac  embarrassment.  It  is,  however,  rather  proportionate  to  the 
degree  of  toxemia.  It  is  striking  even  in  cases  in  which  the  lung  is  not 
involved.  When,  however,  pneumonia  obtains,  the  cyanosis  deepens. 
Under  ordinary  circumstances  this  is  accompanied  by  dyspnoea;  but 
less  often  in  influenzal  pneumonia  than  in  lobar  pneumonia.  This  may 
be  due  to  differences  in  carbon  dioxide  content  of  the  blood,  for  the 
respiratory  centre  is  more  susceptible  to  carbon  dioxide  increase  than 
oxygen  decrease. 

Even  in  normal  men  neither  the  red  cells  nor  the  plasma  is  fully 
saturated.  Rudolf  says  "  after  all  it  is  the  amount  of  oxygen  in  the 
plasma  that  counts,"  for  it  is  the  intermediary  carrier  of  oxygen  between 
the  red  cell  and  tissues.  Normally,  according  to  him  100  c.c.  of  plasma 
contain  0.35  c.c.  of  oxygen,  but  by  increasing  the  oxygen  in  the  inspired 
air  it  can  be  made  to  take  up  nearly  3  c.c.  Normal  undersaturation  of 
the  arterial  blood  amounts  to  5  per  cent,  and  in  pneumonia  may  amount 
to  18  per  cent.  Finally  anoxemia,  long  continued,  is  damaging  to  tissue, 
especially  nerve  tissue,  as  is  illustrated  by  the  degenerative  processes 
occurring  in  the  brains  of  carbon  monoxide  gas  poisoning  not  imme- 
diately fatal.  Meakins  was  able  to  reduce  this  undersaturation  in 
pneumonia  to  just  over  3  per  cent,  by  oxygen  inhalation. 

All  this  to  justify  the  procedure  of  oxygen  inhalation  in  the  cyanosis 
and  dyspnoea  in  pneumonia.  The  mode  of  administration  is  discussed 
above.  I  have  had  patients  who  found  so  much  relief  that  they  begged 
for  the  repeated  administration  of  it. 

Cough.  This  is  often  exceedingly  harassing;  nothing  but  severe 
whooping  cough  has  equalled  it  in  some  of  the  cases.  In  most  instances 
it  may  be  attributed  to  the  tracheal  inflammation.  It  tires  the  patient 
out,  interferes  with  sleep,  burdens  a  weak  heart  and  facilitates  the  spread 
of  the  infection  through  the  bronchial  tree.  Morphine  or  its  derivatives 
are  indicated.  One  may  try  first  codeine  phosphate  in  doses  of  gr.  }/± 
to  even  gr.  i  (0.015-0.060  Gm.)  by  mouth  or  better  yet  hypodermically, 
repeating  it  at  2  to  4  hour  intervals,  if  needed.  Heroine  has  been  found 
to  control  cough  in  some  cases  that  would  not  yield  to  codeine.  The 
dose  of  the  hydrochloride  is  gr.  1/12-1/10  (0.005-0.006  Gm.)  or  with 
caution  more.  It  must  be  remembered  that  this  drug  is  a  powerful 
respiratory  repressant. 


EPIDEMIC  INFLUENZA  251 

Morphine  sulphate  in  the  most  persistent  cases  is  needed  in  doses  of 
gr.  1/8  to  gr.  K  (0.008-0.015  Gm.)  hypodermically  and  as  often  as  it 
is  deemed  that  the  continued  cough  is  causing  exhaustion. 

Spraying  the  throat  or  more  properly  the  trachea,  by  having  the 
patient  breathe  deep  during  a  spraying  with  2  per  cent,  cocaine  hy- 
drochloride  has  nicely  controlled  cases  under  our  observation  that 
resisted  all  drug  medication. 

If  a  generalized  bronchitis  alone  is  responsible  for  the  cough  it  is  likely 
to  be  less  violent  and  nagging.  Cupping  the  chest  (for  technique, 
see  Chap.  IX)  or,  and,  especially  in  children,  mustard  paste  (1-8  in 
children,  1-4  or  even  stronger  in  adults)  may  be  tried.  (For  technique, 
see  Chap.  IX.)  In  pleuritic  cases  a  hard,  nagging,  unproductive  cough 
may  be  caused  by  the  exudate.  The  most  effectual  treatment  is 
strapping  the  chest,  though  countei  irritation  with  mustard  may  be  tried. 

Acidosis.  We  know  this  not  infrequently  occurs  in  pneumonia. 
If  laboratory  facilities  are  at  hand  the  presence  or  absence  of  acidosis 
may  be  determined,  for  example  by  the  Van  Slyke  method  of  deter- 
mining carbon  dioxide  combining  power  of  the  blood.  When  such 
assistance  is  not  at  hand  Sellards'  method  may  be  applied.  This 
depends  on  the  knowledge  that  the  acidity  of  a  normal  urine  may  be 
neutralized  by  the  ingestion  of  4  to  8  grams  of  bicarbonate  of  soda.  If 
one  administers  4  grams  (3  i)  of  bicarbonate  at  two-hour  intervals,  the 
number  of  doses  required  to  get  a  neutral  urine  gives  a  rough  measure  of 
the  degree  of  acidosis,  while  at  the  same  time  correcting  it.  I  have  liked 
to  recommend  the  administration  of  bicarbonate  in  the  influenzal  pneu- 
monias, lest  one  be  caught  unawares. 

Tympanites.  In  my  experience  tympanites  was  not  as  constant 
as  in  ordinary  lobar  pneumonia;  but  it  occurred  often  enough  and 
demanded  earnest  attention.  Its  presence  added  to  both  the  respiratory 
and  circulatory  difficulties  and  contributed  to  gastro-intestinal  disturb- 
ances. The  methods  used  to  relieve  this  condition  are,  first,  elimina- 
tion of  easily  fermenting  foods,  such  as  cereals  and  sugars,  giving  of  a 
sufficiency  of  water;  the  application  of  stupes,  either  plain  or  turpen- 
tine stupes  (for  technique,  see  Typhoid  Fever,  Chap.  XIV),  and  the 
introduction  of  the  rectal  tube  some  eight  or  ten  inches  with  an  occa- 
sional turning  of  the  patient  from  side  to  side,  a  procedure  which  also 
lessens  hypostatic  congestion  of  the  lung  and  better  aeration  of  the 
unimpaired  air  vehicles. 

Enemata  may  be  tried,  the  plain  enema,  soapsuds  enema  (for  tech- 
nique, see  Index)  turpentine  enema  (for  technique,  see  Index) ,  milk  and 
molasses  enema  (for  Technique,  see  Index)  and  peppermint  enema  (for 
technique,  see  Index).  Pituitrin  in  1  c.c.  doses  intravenously  is  often  of 


252  TREATMENT  OF  ACUTE  INFECTIOUS  DISEASES 

great  value.  Its  stimulating  action  on  the  vaso-motor  system  is  an  added 
desideratum.  Strychnine  sulphate  in  doses  of  gr.  1/60-gr.  1/30  (0.001- 
0.002  Gm.)  hypodermically  is  credited  with  energizing  the  wall  of  the  gut. 

Delayed  Resolution  was  not  uncommon,  ,?the  physical  signs  and 
X-ray  evidence  of  persistent  consolidation  or  infiltration  lasting  weeks 
after  fever  has  subsided. 

Use  of  Convalescent  Serum.  Serum  obtained  from  convalescent 
patients  had  recently  come  into  use  in  the  treatment  of  other  conditions 
(see  Scarlet  Fever,  Chap.  XVIII) ;  so,  in  the  absence  of  any  serum 
elaborated  from  animals  except  in  those  cases  in  which  the  pneumonia 
was  proven  to  be  caused  by  Type  I  pneumococcus,  it  was  natural  to 
think  of  the  whole  blood  or  serum  of  convalescents  as  probably  con- 
taining antibodies  utilizable  in  acute  cases. 

Transfusion  was  done  in  some  cases,  using  the  method  detailed  under 
Septicemia,  Chap.  XLV,  but  more  convenient  was  the  use  of  serum  ob- 
tained from  one  individual  or,  better  yet,  pooled  serum  from  a  large 
number.  It  was  only  in  certain  hospitals  (notably  the  Naval  Hospital 
in  Chelsea,  Mass,  that  this  was  done,  though  it  was  perfectly  feasible  in 
any  community  if  health  authorities  had  taken  the  matter  in  hand. 
Pooling  has  the  advantage  of  higher  antibody  titre  than  one  might  get 
from  a  single  individual. 

Blood  was  withdrawn1  as  early  as  ten  days  after  the  temperature 
was  normal  and  as  late  as  six  weeks  after  in  patients  in  whom  a  Wasser- 
mann  had  been  reported  negative  and  who  gave  no  history  or  evidences 
of  syphilis  or  other  communicable  diseases.  The  serum  was  separated 
and  added  to  a  common  stock  preserved  by  the  addition  of  0.3  per  cent, 
strength  tricresol  and  stored  in  an  ice  box.  It  was  preferred  to  obtain 
serum  from  patients  who  had  had  pneumonia,  as  the  titre  was  found 
not  so  high  in  simple  influenza  cases  and  the  content  of  antibody  seemed 
to  be  much  higher  in  those  who  had  survived  a  severe  case.  The  amount 
used  is  limited  only  by  the  difficulty  of  obtaining  it,  but  the  usual  dose 
was  120  c.c.  given  one  to  three  or  more  times  at  eight-hour  intervals, 
depending  on  the  reaction  of  the  patient.  The  procedure  of  administra- 
tion will  be  found  in  detail  under  Pneumonia,  Chap.  IX,  but  the  pre- 
cautions to  detect  sensitization  are  not  necessary,  as  here  human,  not 
horse  serum,  is  used. 

1  Withdraw  serum,  put  in  incubator  at  body  temperature  for  one  hour,  at 
•which  time  100  c.c.  of  serum  may  be  separated  from  500  c.c.  of  blood.  If  there 
is  no  haste,  place  the  blood  in  the  refrigerator  5-6-18  hours.  Then  decant  and 
centrifuge  the  serum  to  separate  all  formed  elements;  175-250  c.c.  of  serum  will 
separate  from  500  c.c.  of  blood.  Add  to  each  100  c.c.  of  serum  20  c.c.  of  a  1.5 
per  cent,  tricresol  solution  in  normal  saline.  This  gives  a  final  tricresol  content 
of  0.3  per  cent.  The  pooled  serum  will  keep  in  the  ice  box  5-6  weeks. 


EPIDEMIC  INFLUENZA  253 

There  can  be  no  question  that  if  the  serum  was  used  early,  its  value 
would  be  much  enhanced;  but  in  private  practice  the  difficulties  incident 
upon  getting  donors  and  separating  the  serum  will  result  in  its  being 
chosen  only  in  severe  and  late  cases,  unless  in  case  of  another  epidemic  a 
concerted  move  on  the  part  of  health  authorities  affords  a  serum  of  rela- 
tively easy  access. 

In  a  paper  read  before  the  Massachusetts  Medical  Society  by  Redden 
the  results  obtained  in  100  private  cases  were  cited.  In  the  discussion 
which  ensued  issue  was  taken  with  the  proposition  that  the  statistical 
evidence  was  sufficient  to  prove  it  superior  to  other  methods  including 
their  own  experiences;  but  while  taking  this  ground  with  reference  to  the 
statistics,  his  critics  expressed  themselves  as  impressed  by  individual 
instances  and  frankly  said  that  under  similar  circumstances  they  should 
want  the  serum  administered  to  themselves.  I  myself  utilized  both  the 
transfusion  and  the  convalescent  serum  in  several  instances  and  find  it 
hard  to  pass  judgment  on  the  result,  but  feel  that  I,  too,  if  very  ill  with  in- 
fluenzal  pneumonia  would  be  glad  to  have  convalescent  serum  given  me. 

Pleurisy  and  Empyema.  In  the  early  epidemic  of  1918  pleurisies 
were  relatively  rare,  but  in  the  later  recurrent  epidemic  were  present  in 
60  per  cent,  of  the  cases;  in  40  per  cent,  there  were  purulent  or  semi- 
purulent  effusions.  This  extraordinary  change  in  the  reaction  of  the 
tissues  in  the  first  appearance  of  the  epidemic  and  later  was  only  one  of 
many  such  differences.  In  the  epidemic  of  1918  the  physical  signs  of  an 
effusion  were  common  enough,  but  the  needle  went  into  the  enormously 
congested  lung  in  which  fluid  within  the  lung  simulated  fluid  without  the 
lung;  but  in  the  recurrence  of  the  epidemic  it  was  not  uncommon  to  over- 
look fluid  in  the  pleural  cavity  which  occurring  over  massive  consolida- 
tions only  accentuated  the  physical  signs  of  consolidation,  instead  of 
giving  rise  to  loss  of  bronchial  voice  and  breathing  (Norris  and  Landis) . 
The  displacement  of  the  apex  of  the  heart  is  a  differential  point  of  car- 
dinal significance,  as  pointing  to  fluid.  The  needle  settles  the  question, 
or  if  X-ray  facilities  are  at  hand,  the  plate  tells  the  tale. 

Not  only  may  the  effusion  occur  early,  but  it  may  occur  late  or  after 
the  temperature  has  fallen.  When,  then,  the  temperature  is  sustained 
unduly  long  and  takes  on  a  remittent  character  or  when  it  falls  to  normal 
and  then  shoots  up  again  one  should  suspect  a  purulent  effusion.  It  may 
be  diffuse,  when  its  detection  by  physical  signs  and  needling  is  compara- 
tively easy  or  it  may  be  encapsulated,  or  interlobar  when  it  is  not  so 
easy  to  locate  either  by  one  or  the  other  and  finds  its  problem  best  re- 
solved by  the  X-ray. 

When  the  needle  withdraws  sero-purulent  or  purulent  fluid  the  best 
procedure  seems  to  be  aspiration  as  a  preliminary  to  later  operation. 


254  TREATMENT  OF  ACUTE  INFECTIOUS  DISEASES 

This  allows  the  compressed  lung  to  expand  again  and  the  displaced  heart 
to  come  back  towards  its  normal  position. 

The  pleurisies  show  a  tendency  to  become  plastic  very  quickly,  the 
result  is  a  walling  off  or  localization  of  the  process  and  at  the  same  time 
makes  for  dense  adhesions  and  for  later  crippling  of  the  lung.  These 
empyemata  are  often,  if  not  usually,  due  to  the  rupture  of  tiny  pul- 
monary abscesses  lying  very  near  the  surface  of  the  lung;  and  as  these 
are  likely  to  be  multiple  and  the  plastic  exudate  promptly  walls  them  off, 
a  number  of  loculated  pus  collections  is  the  result,  which  have  to  be 
individually  emptied  and  whose  walls  have  to  broken  down  at  operation. 
It  is  the  failure  to  accomplish  this  that  defeats  the  operative  endeavor 
and  perpetuates  the  infection.  The  X-ray  affords  much  assistance  in 
determining  sacculated  empyemata;  but  it  has  decided  limitations  that 
the  surgeon  should  appreciate. 

When  by  aspiration  the  pressure  on  the  circulation  has  been  relieved 
the  immediate  danger  is  over.  It  seems  now  to  be  the  judgment  of 
surgeons  to  wait  for  further  procedure  until  the  acute  stages  of  the 
infection  are  passed,  unless  pressure  demands  further  aspiration.  In  the 
meantime  the  walling  off  process  is  more  complete  and  the  exudate 
thickens.  When  the  pus  has  become  of  a  creamy  consistency,  operative 
procedure  is  much  safer. 

Lilienthal  prefers  for  aspiration  mere  evacuation  by  trochar  and 
cannula  to  which  a  rubber  tube  is  later  attached,  to  a  Potain  apparatus. 
There  is  no  objection  to  the  small  amount  of  air  that  enters  by  the  proc- 
ess, in  fact  it  lessens  the  shock  of  the  procedure  and  the  air.  may  be 
expelled  by  the  patient's  straining  with  the  glottis  closed  until  bubbles 
cease  to  appear  from  the  end  of  the  rubber  tube  held  under  water.  The 
instrument  is  inserted  through  a  small  incision  between  the  ribs,  in  the 
most  dependent  part  of  the  chest,  the  patient  lying  on  the  edge  of  the 
bed.  For  continuous  drainage,  the  use  of  Dakin's  solution  and  thora- 
cotomy,  text-books  on  Surgery  should  be  consulted. 

For  details  of  treatment  of  an  influenzal  type  of  empyema  the  reader  is 
referred  to  Chap.  X  on  streptococcus  pneumonia. 

Abscess  of  the  Lung.  The  striking  difference  in  the  incidence 
of  pulmonary  abscess  in  the  beginning  of  the  epidemic  and  that  occurring 
later  is  another  of  the  variations  difficult  to  understand. 

At  first  according  to  Symmers,  "intrapulmonary  abscesses  were 
virtually  unknown  accompaniments  of  the  pneumonic  process."  In  the 
recurrent  epidemic  he  met  them  in  over  a  third  of  the  cases  and  when  the 
pleura  was  involved  he  met  multiple  small  pleural  and  subpleural  ab- 
scesses in  nearly  half  his  autopsies. 

Of  course,  many  of  these  resolve,  but  larger  ones  account  for  the  con- 


EPIDEMIC  INFLUENZA  255 

tinuance  of  fever  and  evidences  of  infection  in  the  absence  of  empyema. 
The  X-ray  is  of  material  assistance  in  determining  these.  An  abscess 
may  rupture  into  the  bronchus  and  discharge  in  the  expectoration.  At 
times  this  discharge  may  be  very  foul  and  may  run  into  a  chronic  process. 
This,  of  course,  prolongs  the  disease  for  an  indefinite  period  and  entails 
loss  of  flesh  and  strength  and  a  secondary  anemia.  The  patient  should  be 
kept  in  the  open  air  and  sunlight,  much  as  a  tuberculosis  patient.  A 
sufficiency  of  diet  must  be  maintained,  and  it  is  the  physician's  duty  to 
know  approximately  how  many  calories  a  day  this  represents  and  en- 
deavor to  approximate  3,000  calories. 

The  sputum  should  be  cultured  and,  if  a  dominant  organism,  strep- 
tococcus, staphylococcus,  Pfeiffer's  bacillus  or  Friedlander's  can  be 
secured,  a  vaccine  may  be  made  and  administered.  (For  technique, 
see  Index.) 

Drugs  are  of  questionable  value  and  for  that  reason  any  that  are  likely 
to  disturb  the  stomach  should  be  avoided. 

Guiacol  Carbonate  in  gr.  ii  (0.120  Gm.)  doses  every  three  or 
four  hours  might  be  tried  and  if  there  is  much  fetor  an  inhalation  of  a 
mixture  composed  of  equal  parts  of  alcohol,  chloroform  and  creosote,  is 
to  be  recommended.  This  is  best  accomplished  by  the  use  of  a  perfor- 
ated zinc  inhaler,  sometimes  spoken  of  as  a  Robinson's  Inhaler,  which 
is  worn  over  the  nose  and  mouth,  held  on  by  elastics  passed  over  the  ears. 
One  drops  10  drops  of  the  mixture  on  the  moistened  sponge  of  the  inhaler 
to  be  renewed  as  needed.  The  mask  may  be  worn  as  much  of  the  time  as 
the  patient  desires. 

The  abscess  may  break  through  into  the  pleura  and  be  followed  by  an 
empyema.  This  indicates  a  surgical  procedure  and  presents  a  little 
different  problem  from  the  usual  one.  (For  technique,  see  special  text- 
books.) 

Bronchiectasis.  This  may  occur  acutely  in  the  course  of  the  dis- 
ease, prolonging  the  course  and  passing  into  a  chronic  condition  or  it 
may  come  on  gradually,  first  giving  symptoms  years  after  the  attack. 

Tuberculosis.  It  seems  probable  that  influenza  is  responsible  for 
the  lighting  up  of  a  tuberculous  process;  but  one  must  keep  well  in  mind 
that  influenza  pneumonias  in  the  upper  lobe  may  so  simulate  the  physical 
signs  of  tuberculosis,  and,  indeed,  present  an  X-ray  picture  so  like  it, 
that  an  error  in  diagnosis  is  readily  made.  This  difficulty  is  enhanced 
by  the  fact  that  such  influenza  pneumonias  are  often  very  slow  in  resolv- 
ing. Such  patches  of  pneumonia  at  the  bases  should  hardly  suggest 
tuberculosis. 

In  all  these  upper  lobe  cases  without  previous  history,  one  should 
lean  to  a  favorable  diagnosis,  but  in  no  way  neglect  to  examine 


256  TREATMENT  OF  ACUTE  INFECTIOUS  DISEASES 

the  sputum  repeatedly  and  carefully  watch  the  development  of  the 
case. 

Much  more  difficult  is  the  problem  presented  by  a  persistent  infiltra- 
tion of  either  upper  lobe  after  influenza  and  in  -a  patient  who  is  known  to 
have  had  an  old  tubercular  process.  The  prognosis  here  must  be  most 
guardedly  given.  Only  the  progress  of  the  case  and  repeated  'examina- 
tions of  the  sputum  can  make  a  decision.  Finally,  it  must  be  remem- 
bered that  tuberculous  pneumonia  may  simulate  lobar  pneumonia.  A 
prolonged  course,  remittent  and  intermittent  type  of  fever,  anemia, 
wasting,  sweating  or  an  old  tubercular  history,  or  hemoptysis  or  pleurisy 
in  the  past  give  the  clue,  and  examinations  of  the  sputum  clinch  it. 
Tuberculosis  determined,  is  to  be  treated  as  under  other  circumstances. 

Emphysema.  It  has  been  noted  how  characteristic  acute  em- 
physema was  in  the  pulmonary  lesions  of  influenza.  Many  cases  of 
subcutaneous  emphysema  were  reported.  I  saw  such  with  exten- 
sive infiltration  of  the  tissues  of  the  neck,  face  and  thorax,  presenting 
the  peculiar  crackle  on  palpation,  characteristic  of  air  in  the  subcuta- 
neous tissues.  The  air  is  derived  from  ruptured  vesicles  in  the  lung, 
burrowing  to  the  root  of  the  lung,  mediastinum  and  fascial  planes  of  the 
neck,  or  may  originate  from  rupture  of  vesicles  beneath  the  mediastinal 
pleura  or  at  apices. 

The  condition  needs  no  interference.  The  air  is  later  absorbed  by 
the  tissue. 

Upper  Air  Passages.  It  seemed  to  me  that  considering  the 
severity  of  the  inflammations  affecting  bronchi,  trachea  and  lungs  that 
the  upper  air  passages  showed  a  singular  freedom  from  complications. 
Nasal  congestion  occurred  and  probably  played  its  role  in  some  of  the 
headaches.  Its  treatment  has  been  dealt  with  above.  Epistaxis  was 
common  enough,  but  rarely  of  such  proportions  as  to  need  interference. 
However,  cases  of  coryza,  tonsillitis,  pharyngitis,  laryngitis,  sinusitis 
and  otitis  do  occur  and  are  to  be  treated  as  under  other  circumstances. 
(See  these,  Chaps.  IV,  V,  VI.) 

Heart  and  Vessels.  The  heart  did  not  appear  so  seriously 
affected  as  one  might  have  anticipated  and  yet  at  autopsy  extreme 
dilatation  of  the  right  side  of  the  heart  was  not  uncommon.  In  the  early 
days  of  the  epidemic  the  myocardium  was  deeply  congested,  but  in 
later  cases  acute  parenchymatous  degeneration  with  flabby  and  friable 
muscle  was  a  frequent  finding. 

The  endocardium  escaped  and  the  pericardial  involvement  was  not 
common  though  it  did  occur,  and  in  some  instances  was  found  to  con- 
tain a  purulent  exudate. 

The  treatment  of  a  failing  circulation  has  been  set  out  above.    Peri- 


EPIDEMIC  INFLUENZA  257 

carditis  is  treated  as  under  other  circumstances.  (See  Acute  Rheumatic 
Fever,  Chap.  III.)  A  relatively  slow  pulse,  maintaining  striking  regu- 
larity, was  a  feature  of  the  disease  during  its  height;  but  in  convalescence 
evidences  of  irritability  of  its  nervous  and  muscular  apparatus  was  not 
uncommon.  One  saw  continued  bradycardia,  tachycardia,  premature 
systoles  and  sinus  arhythm.  I  saw  one  case  of  complete  block,,  not 
attributable  to  digitalis,  and  auricular  fibrillation  has  been  reported. 

Treatment.  Irregularities  of  the  type  mentioned  above  except 
fibrillation  rarely  require  interference.  Premature  systoles,  if  annoying 
and  occurring  in  convalescence,  should  indicate  the  elimination  of  such 
excitants  as  tea,  coffee  and  tobacco;  and  bromides  in  moderate  doses 
gr.  x-xv  (0.066-1  Gm.)  three  times  a  day  may  be  given.  This  should  be 
continued  but  a  short  time,  a  week,  and  a  course  of  strychnine  sulphate 
gr.  1/60-1/30  (0.001-0.002  Gm.)  three  times  a  day  given  after  the  bro- 
mides, may  be  helpful  or  bromides  gr.  x  (0.66  Gm.)  and  tincture  of  nux 
vomica  m.  xv  (1  c.c.)  may  be  given  together  three  times  a  day. 

Tachycardia  may  be  long  persistent.  It  is  important  to  determine 
whether  this  is  due  to  a  disordered  nerve  mechanism  or  to  a  weakened 
myocardium.  Dyspnoea  on  exertion,  cardiac  dilatation  and  impairment 
of  sounds  and  electrocardiographic  evidence  help  us  in  determining  the 
question.  If  the  myocardium  is  involved  the  case  should  be  treated  as 
cardiac  inefficiency,  rest,  regular  diet  and  suitable  doses  of  digitalis. 
If  a  simple  tachycardia,  tonic,  fresh  air,  good  food,  freedom  from  worry 
and  regulated  rest,  exercise  and  work  is  all  that  is  needed. 

Bradycardia,  not  due  to  block,  and  sinus  arhythm  requires  no  inter- 
ference other  than  moderation  on  the  part  of  the  patient.  Heart  block 
is  common  to  many  infectious  diseases  and  disappears  of  itself  as  a  rule. 
While  it  obtains  and  more  particularly  if  any  cardiac  decompensation 
accompanies  it,  rest  should  be  observed. 

Auricular  fibrillation  may  disappear,  but  is  likely  to  be  permanent. 
I  should  suspect  previous  damage  to  the  myocardium.  It  should  be 
treated  as  under  other  circumstances,  much  depending  on  evidences 
of  decompensation. 

Phlebitis  has  been  reported  as  a  rare  happening.  It  should  be  treated 
as  detailed  in  Typhoid  Fever.  Allbutt  tells  us  that  influenza  is  one  of 
the  less  common  causes  of  toxic  arteriosclerosis,  seen  more  commonly 
after  typhoid;  also  that  it  causes  an  aortitis  with  involvement  of  the 
middle  coat  as  in  syphilis  and  that,  as  in  the  latter,  aneurisms  and  angina 
pectoris  may  result.  This  was  written  before  the  present  epidemic. 
Whether  we  shall  see  such  late  results  of  this  visitation  remains  for  the 
future  to  determine. 

Kidneys.     Acute    parenchymatous    degeneration    of    the    kidney 


258  TREATMENT  OF  ACUTE  INFECTIOUS  DISEASES 

occurred,  more  marked  later  in  the  epidemic ;  but  I  saw  no  cases  of  renal 
inadequacy.  Hemmorrhagic  nephritis  has  been  reported,  however,  as 
occurring  early  and  especially  in  children;  clinical  nephritis  seems  to 
have  been  reported  more  frequently  from  abroad  than  in  this  country. 
When  nephritis  occurs  it  should  be  treated  as  if  a  primary  disease.  (See 
Scarlet  Fever,  Chap.  XVII.) 

Infections  of  the  Kidney.  It  has  been  emphasized,  especially 
by  Bugbee,  that  infections  of  the  kidney  were  not  rare  happenings  and 
that  they  have  been  all  too  frequently  overlooked.  Cases  of  pyelone- 
phrosis  and  perinephritic  abscesses  were  observed.  Pyelonephritis  was 
recognized  by  "pain  and  tenderness  in  the  kidney  region;  frequent, 
burning,  painful  urination,  high  temperature,  chills,  malaise"  (Bugbee). 
Cystoscopy  confirmed  the  diagnosis.  Colon  bacillus  was  the  organism 
most  commonly  found,  but  staphylococcus  and  possibly  influenza 
bacilli  were  also  noted.  Treatment — drainage  by  catheter,  pelvic  lavage, 
urinary  antiseptics,  colon  irrigations  and  appropriate  diet  was  recom- 
mended. Perinephritic  abscess  gives  rise  to  pain  and  tenderness  in 
the  lumbar  region,  continued  temperature,  often  chills  and  often  bulg- 
ing in  the  flank.  Incision  and  drainage  are  indicated.  Other  infections 
of  the  genito-urinary  tract  that  have  been  reported  include  epididy- 
mitis,  seminal  vesiculitis  and  prostatic  abscesses.  For  local  and  sur- 
gical treatment  one  should  consult  works  on  genito-urinary  diseases. 

Nervous  System.  Meningitis,  due  to  the  PfeifTer  organism, 
is  reported  from  time  to  time  as  sporadic  cases,  but  during  the  recent 
epidemic,  strange  to  say,  no  greater  number  of  cases  of  meningitis  due 
to  this  organism  were  noted  than  on  inter-epidemic  years.  It  was  noted 
by  Neal  in  her  work  under  the  Department  of  Health  of  New  York  City 
that  a  larger  number  of  meningococcus  cases  were  met  with  during  the 
epidemic  than  during  the  same  season  in  other  years.  This  may  have 
been  a  coincidence  or  the  influenza  epidemic  may  have  played  a  role 
as  a  contributing  factor.  Neal  noted  a  considerable  number  of  cases 
of  meningismus  (serous  meningitis)  that  occurred,  strangely  enough, 
during  convalescence  rather  than  at  the  height  of  the  infection  as  is 
usual  in  the  case  of  meningismus  in  most  acute  infections.  These  cases 
had  all  the  usual  signs,  symptoms  and  cord  findings  and,  as  is  the  usual 
result,  were  relieved  by  simple  lumbar  puncture. 

The  treatment  of  true  meningitis  cases  is  symptomatic.  (See  Cerebro- 
spinal  Meningitis,  Chap.  XXV.)  It  would  be  interesting  to  note  the  re- 
sults of  intraspinal  treatment  with  convalescent  serum  in  cases  of  true 
influenzal  meningitis,  but  no  cases  have  been  reported  to  my  knowledge. 
Meningismus  indicates  lumbar  puncture  as  a  therapeutic  procedure. 

Encephalitis  Lethargica.    There  seems  to  be  some  sort  of  re- 


EPIDEMIC  INFLUENZA  259 

lationship  between  influenza  epidemics  and  encephalitis  lethargica. 
This  is  discussed  under  that  heading  in  Chap.  XIII. 

Neuritis.  Affections  of  a  single  nerve  and  polyneuritis  has 
been  reported  after  influenza,  and  an  epidemic  of  polyneuritis  occurred 
with  the  present  epidemic  that  seemed  to  be  a  peripheral  equivalent 
of  encephalitis  lethargica. 

Mental  Disturbance.  Aside  from  the  delirium  accompanying 
an  attack  of  influenza,  and,  indeed,  more  important  are  the  mental 
aberrations  following  it.  The  disease  seems  to  bring  out  and  precipitate 
those  mental  disorders  to  which  a  patient  may  be  predisposed. 

Delirium  may  occur  early  and  be  mistaken  for  acute  mania.  Moderate 
delirium  does  not  prejudice  the  outcome,  but  excessive  delirium  gives 
a  bad  prognosis. 

Depression  or  mental  hebetude  may  characterize  the  attack  and  I 
recall  such  cases  in  whom  the  absolute  absence  of  any  response  to  ques- 
tions or  the  absence  of  effort  in  patients  apparently  fully  conscious 
seemed  almost  wilful. 

Psychasthenia  accompanied  by  neurasthenia  is  the  most  common 
sequel.  Burr  says  it  is  so  frequent  that  it  should  be  considered  rather 
a  part  and  parcel  of  the  disease  than  a  complication.  Profound  weak- 
ness, tachycardia  and  sweating  on  effort,  disinclination  or  inability  to 
mental  effort,  fretfulness  or  depression,  even  to  melancholia  with  sui- 
cidal tendencies  are  the  usual  expressions.  Burr  says  the  outlook  for 
complete  recovery  from  psychasthenia  and  neurasthenia  is  absolutely 
good  and  even  from  simple  melancholia  unless  delusions  of  self-accu- 
sations occur. 

Depressed  patients  should  always  be  watched  lest  suicide  be  at- 
tempted. 

From  a  few  days  to  a  few  weeks  after  beginning  convalescence  forms 
of  insanity  may  appear  in  the  predisposed.  It  may  take  the  form  of 
confusional  insanity  in  whom  after  a  duration  of  five  to  eight  weeks  the 
prognosis  for  recovery  is  good  (Burr). 

Influenza  seems  to  bring  out  in  the  young  the  dementia  precox  to 
which  they  have  a  tendency ;  in  alcoholics,  delirium  tremens,  and  in  cer- 
tain old  syphilitics,  paresis. 

Treatment.  Food,  which  especially  in  the  depressed,  requires 
some  tact  to  administer  in  sufficient  quantity.  Rest  at  first,  followed 
by  massage  and  then  graduated  exercises.  Fresh  air.  Attention  to  the 
bowels  with  mild  cathartics  especially  in  the  depressed  and  melan- 
cholies who  have  a  tendency  to  constipation. 

In  the  forms  of  mental  disturbance  associated  with  excitement,  the 
continuous  warm  bath  is  of  value  as  a  sedative. 


260  TREATMENT  OF  ACUTE  INFECTIOUS  DISEASES 

Abdominal  Symptoms.  Aside  from  gastro-intestinal  disturb- 
ances considered  above,  one  meets  with  occasional  cases  of  abdominal 
pain  that  may  give  rise  to  confusion.  There  is  a  curious  hyaline  de- 
generation of  the  rectus  muscle  of  the-*  abdomen  (Zenker's  de- 
generation) into  which  extravasations  of  blood  sometimes  occur  and 
streptococcus  infections  with  abscess  formations.  This  is  to  be  thought 
of  in  cases  of  localized  pain  in  the  rectus  muscle. 

Like  any  pneumonia  in  which  there  is  a  diaphragmatic  pleurisy  and 
involvement  of  the  lowermost  area  of  the  costal  pleura,  one  has  referred 
pain  that  may  be  mistaken  for  appendicitis,  or  one  of  the  several  lesions 
affecting  the  upper  right  quadrant.  I  recall  one  such  in  which  severe  pain 
in  the  upper  right  quadrant  with  a  considerable  jaundice  simulated 
cholelithiasis  before  the  pulmonary  signs  came  out. 

Otitis  Media.  While  not  the  common  happening  that  one  might 
expect  in  a  disease  affecting  the  air  passages  throughout  such  an  extent, 
otitis  media  was  met  with  often  enough  to  warn  the  practitioner  to 
be  on  the  lookout  for  the  condition.  In  our  experience  at  Bellevue  in 
500  cases  of  influenza  admitted  in  October,  1918, 4  per  cent,  developed 
otitis  media.  Of  this  number  fully  one-half  gave  no  complaint  referable 
to  the  ear.  These  cases  were  discovered  by  the  routine  practice  of  ear 
examination  established.  It  must  be  said  that  this  is  a  much,  higher 
percentage  than  I  met  with  in  private  practice.  For  treatment,  the 
reader  is  referred  to  Scarlet  Fever,  Chap.  XVII. 

Parotitis.  This  is  a  rare  happening  and  although  I  have  no 
statistics  I  should  conjecture  it  is  no  more  common  than  in  lobar  pneu- 
monia. (For  treatment,  see  Lobar  Pneumonia,  Chap.  IX.) 

Abscess  of  the  Muscles.  This  is  an  occasional  complication. 
Three  such  cases  occurred  in  our  service  at  Bellevue.  They  occurred 
in  the  muscles  of  the  calf  and  in  those  of  the  buttocks  and  as  noted  above 
in  the  recti  at  the  site  of  the  hyaline  degeneration  of  Zenker. 

The  treatment  should  consist  in  immobilization  and  the  application  of 
wet  dressings  and  later  incision  and  drainage. 

Convalescence.  No  period  of  illness  is  more  commonly  neg- 
lected than  convalescence.  In  part  this  is  due  to  the  patient,  who  for 
reasons  of  economy  wishes  to  dispense  as  soon  as  possible  with  the  doc- 
tor's services,  and  in  part  to  the  physician,  attracted  by  more  urgent 
cases  and  all  too  often  unappreciative  of  the  importance  of  this  period. 
The  careful  observations  of  Army  physicians  has  impressed  us  with  the 
long  periods  after  infections,  which  in  civil  practice  we  are  inclined  to 
treat  as  trivial,  it  takes  to  restore  a  man  to  military  fitness.  I  am  con- 
vinced that  we  err  as  a  rule  in  shortening  this  period  to  the  detriment  of 
the  patient. 


EPIDEMIC  INFLUENZA  261 

Even  after  the  mildest  attacks  of  influenza  it  is  well  to  keep  the  patient 
in  bed  at  least  two  full  days  after  the  temperature  is  normal  and  forbid 
resumption  of  normal  duties  for  a  week.  After  a  severe  case  or  a  pneu- 
monia the  patient  should  remain  in  bed  ten  days  at  least  and  then  be 
allowed  to  get  about  gradually.  It  should  require  at  least  two  weeks 
more  before  any  duties  are  resumed,  but  in  my  estimation  the  period 
should  be  prolonged  for  several  weeks  with,  if  possible,  a  change  of 
environment.  The  patient  should  feel  and  look  fit  before  undertaking 
his  normal  activities. 

As  has  been  said  above  the  myocardium  needs  watching  and  as  long 
as  poor  heart  sounds,  arhythms,  tachycardias,  low  blood-pressure  or 
evidences  of  cardiac  incompetency  obtain,  the  patient  requires  medical 
care. 

Fresh  air  and  sunlight,  good  food  and  increasing  exercise  do  away 
with  the  necessity  for  drugs.  For  many  patients  a  failure  to  prescribe  a 
tonic  constitutes  a  breach  of  the  contract.  For  such,  I  am  accustomed  to 
prescribe  strychnine  sulphate  in  doses  of  gr.  1/60-1/30  (0.001-0.002  Gm.) 
or  such  a  prescription  as  follows: 

3 

Sodii  Glycerophosphatis 

Tr,  Nucis  Vomicae aa  10        (Siiss.) 

Aq.,  q.  s.  ad 60        (5ii) 

M. 

Sig.    One  teaspoonful  three  times  a  day  in  water  after  meals. 

Prophylaxis.  Theoretically,  keeping  fit  should  lessen  the  inci- 
dence of  the  disease;  but  when  one  observed  the  stalwart  specimens  in 
Army  and  civil  life  that  were  affected — and  the  plague  seemed  in  this 
epidemic  at  least  to  choose  the  young  adult  at  the  very  age  of  physical 
perfection — one  wonders  whether  physical  fitness  played  any  prophy- 
lactic role  whatsoever. 

More  important  was  avoiding  the  conditions  that  lead  to  any  infection, 
contact  with  those  already  infected  and  lessening  resistance  by  fatigue, 
undue  exposure,  remaining  in  wet  clothes,  and  exposure  to  drafts  when 
overheated. 

The  common  carriers,  with  people  herded  like  the  inmates  of  a  slave- 
pen,  must  be  hot-beds  of  infection;  sneezing,  coughing,  laughing  and 
talking,  without  effort  to  prevent  spread  of  secretions  of  nose  and  mouth 
by  the  use  of  a  handkerchief,  constitute  ideal  conditions.  Any  place 
where  crowds  congregate,  theatres  and  other  places  of  amusement, 
dances,  churches,  all  endanger  at  the  time  of  an  epidemic. 

A  man  with  a  "cold"  should  be  mentally  labelled  " unclean"  and 
shunned  accordingly.  Delicacy  and  conventionalities  forbid  us  to  say: 


262  TREATMENT  OF  ACUTE  INFECTIOUS  DISEASES 

"Sir,  you  are  holding  a  revolver  to  my  head  and  are  pressing  the  trigger/7 
but  the  results  unhappily  are  often  the  same  in  either  instance. 

Kissing,  promiscuous  handshaking,  the  use  of  toilet  articles  in  public 
places  and  of  half  cleaned  eating  utensils  m  public  eating  places  are 
all  a  menace. 

When  a  case  occurs  in  a  family,  the  measures  set  out  above  should 
be  observed. 

Vaccines.  We  could  wish  that  we  had  an  efficient  vaccine  for 
prophylactic  purposes;  but  it  is  hard  to  convince  oneself  of  the  value  of 
those  used. 

Vaccines  of  Pfeiffer's  organisms  and  mixed  vaccines  containing  this 
with  pneumococci,  streptococci,  and  staphylococci  were  used. 

The  reports  are  too  conflicting  to  pass  judgment  on  the  value  of  the 
measure.  For  example,  Rosen ow — working  under  the  Mayo  Founda- 
tion— distributed  a  polyvalent  vaccine  of  the  four  types  of  pneumococci, 
streptococci  and  staphylococci,  but  no  influenza  bacilli,  for  prophylactic 
use  by  physicians  in  many  states  but  chiefly  in  Iowa,  Minnesota  and 
Wisconsin  who  reported  back  to  Rosenow.  He  reports  on  a  group  of 
93,476  persons  inoculated  three  times,  and  over  345,000  who  were  not 
vaccinated.  The  incidence  of  the  disease  among  the  fully  inoculated  he 
reports  to  be  one-third  of  that  among  the  uninoculated,  and  the  mor- 
tality among  the  inoculated  to  be  one-fifth  of  that  among  the  uninocu- 
lated. 

Against  this  optimistic  report  stands  that  of  McCoy,  Director  of  the 
Hygienic  Laboratories  of  the  U.  S.  P.  H.  S.  who,  using  vaccines  of  the 
Pfeiffer  organism,  of  the  Pfeiffer  organism  combined  with  the  strepto- 
cocci and  the  polyvalent  vaccine  of  Rosenow,  reported  that  he  could 
determine  no  difference  in  the  incidence  of  disease  and  the  mortality 
among  the  vaccinated  and  un vaccinated  when  the  tests  were  made  under 
controlled  conditions. 

Under  such  circumstances  one  can  but  leave  the  decision  to  the  in- 
dividual practitioner. 

SUMMARY 

Isolation. 

Suspect  and  isolate  every  case  of  cold  during  an  epidemic. 
Infection  promulgated  by  secretions. 

Guard  against  conveyance  by  sneezing,  coughing,  kissing,  handling 
of  handkerchiefs,  soiled  linen  and  eating  utensils. 

Bedroom. 

Choose  with  reference  to  light,  ventilation  and  adjacent  bath  room. 
Strip  of  all  superfluous  furnishings. 


EPIDEMIC  INFLUENZA  263 

Exclude  visitors  and  members  of  family,  except  those  acting  as  nurse. 
Temperature  60°-65°  F.,  colder,  if  grateful. 

In  hospital  service,  separate  patient  by  cubicle  system  or  screens. 
Forbid  dry  sweeping. 

Scrub  floors  with  water  containing  compound  solution  of  cresol  or 
some  other  antiseptic. 

Bed. 

Half  or  three-quarter  width. 

Hospital  type  preferable — Gatch  bed  a  desirable  type. 

Woven  wire  spring  and  even  mattress. 

For  technique  of  making  bed  and  turning  mattress,  see  text. 

Physician. 

Use  gauze  mask.     (For  detail,  see  text.) 
Cleanse  hands  with  soap  and  water  and  such  disinfectants  as  carbolic, 

lysol,  mercuric  bichloride,  alcohol. 
Visit  other  patients  before  influenza  cases  if  possible. 

Nurse. 

Wear  mask — change  frequently. 
Wear  a  gown. 
Cleanse  hands  frequently,  especially  after  handling  patient,  before 

feeding  patient,  going  off  duty  or  eating  meals. 
Cut  nails  close — use  nail  brush. 
Take  rest  and  exercise  in  open  air. 
Eat  regularly. 
Keep  bowels  in  proper  condition. 

Rules  for  the  family. 

Keep  away  from  patient  unless  needed  in  nursing  capacity. 
Avoid  kissing  and  exposure  to  coughs. 
Cover  nose  and  mouth  when  sneezing  or  coughing  as  secretions  are 

infectious. 
Spray  of  2  per  cent,  quinine  sulphate  may  have  prophylactic  value. 

Care  of  patient. 

Rest. 

Good  nursing. 

Well  ventilated  room. 

Daily  bath  of  warm  water  and  castile  soap. 

Keep  skin  dry  with  sterile  toilet  powder. 

For  points  exposed  to  pressure,  massage  and  gentle  alcohol  rubs. 

Care  of  the  mouth. 
Cleanse  with  normal  saline  solution,  4  per  cent,  boric  acid  solution, 

DobelTs  solution,  one-half  to  one-quarter  strength. 
Teeth — brush  gently,  using  simple  dentifrice.    Free  teeth  from  food 

particles. 


264  TREATMENT  OF  ACUTE  INFECTIOUS  DISEASES 

Cleanse  sordes  from  teeth  and  tongue  by  softening  with  half  strength 
solution  of  hydrogen  dioxide.     Scrape  tongue  with  edge  of  whale- 
bone. 
Apply  solution  of: 

"? 
3 

Phenol  (1 :20  watery  solution) 

Glycerin, ; afi  gi  (30) 

Boric  acid  saturated  watery  solution  q.  s.  ad gviii         (240) 

M.  et  S. 

Care  of  the  nose. 

Keep  free  from  secretions. 

Soften  dried  secretions  with  olive  oil  on  cotton  on  wooden  toothpick 

as  applicator.    Spray  with  solutions  mentioned  to  cleanse  mouth. 

May  use  spray  of  1  per  cent,  of  menthol  or  eucalyptus  in  liquid 

petrolatum  (albolene)  or  the  following: 

3 

"Menthol gr.  xxx  (2) 

Camphor gr.  xx  (1.3) 

Eucalyptol gr.  xx  (1.3) 

Ol.  Rosse m.  iii  (0.2) 

Benzoinol,  q.  s.  ad 5ii  (60.0) 

M.  et  S.    Use  in  an  oil  atomizer."    (Coakley.) 

For  frontal  headache. 

Drop  adrenalin  chloride  (epinephrin)  (1:1000)  in  nose  or  dilute  with 
normal  saline  or  Dobell's  1 :4  or  1 :8.    Follow  with  menthol  spray. 

Eyes. 

Cleanse  with  warm  water. 

Conjunctivitis — boric  acid  solution  2%-4%  dropped  into  the  eye 

or  applied  as  cold  compresses. 
Secretions  from  nose,  mouth,  eyes,  should  be  received  on  gauze  placed 

in  paper  bags  and  burned. 

Utensils. 

Should  be  boiled  for  ten  minutes. 

Linen. 

Should  be  immersed  at  once  in  disinfectant  and  later  boiled  for  ten 
minutes. 

Bowels. 

Should  be  opened  early  in  the  illness. 

Children  should  be  given  castor  oil  or  magnesium  citrate  according 

to  age. 
Adults,  castor  oil  5ss.-i  (15-30  c.c.);  Epsom  or  Rochelle  Salt  gss.-i 

(15-30  c.c.). 

Liquor  Magnesii  Citratis,  gviii  (240  c.c.). 

Later,  enemata  if  bowels  do  not  move  as  they  should. 


EPIDEMIC  INFLUENZA  265 

Insist  on  use  of  bed  pan  in  all  very  sick  patients. 
Bedside  commode  may  be  used  for  those  slightly  ill. 
Large  quilted  pads  may  be  used  for  those  unable  to  use  the  bed 
pan. 

Diet. 

Prolonged  cases  3,000  or  more  calories  are  needed. 

Use  milk,  milk  preparations,  milk  soups,  toast,  cereals,  bread,  eggs, 
cream  soups  and  purees,  custards,  jellies,  pineapple  and  other 
fruit  juices,  mutton  and  chicken  broth,  fortify  milk  with  milk  sugar. 

For  further  suggestions,  see  Typhoid  Fever,  Chap.  XIV. 

Do  not  push  early  and  in  highly  toxic  periods. 

Prolonged  cases  require  consideration  of  caloric  needs. 

Fluids. 

Give  fluids  freely. 

Water,  alkaline  waters,  fruit  juices,  lemonade,  orangeade,  grapefruit 
juice,  weak  tea. 

Aches  and  pains. 

Coal-tar  preparations — acetanilid,  acetphenetidin  (phenacetin),  anti- 

pyrin. 
For  example: 

* 

Acetanilid gr.  iss.          (0. 10) 

Sod.  Bicarb gr.  i  (0.066) 

Caffein.  Citrat gr.  ss.          (0.033) 

M.  et  S. 

May  substitute  acetphenetidin  (phenacetin)  in  doses  of     gr.  iii 

(0.20  Gm.)  or  antipyrin  gr.  ii  (0.125  Gm.). 
Combinations   with   sodium   bicarbonate   and    caffeine   may   be 

omitted. 
Salicylates. 

Perhaps  the  best  is  acetylsalicylic  acid  (aspirin)  gr.  v-x  (0.33-0.66 

Gm.)  every  two  hours. 
Combinations  of  acetanilid  gr.  iss.  (0.10  Gm.)  and  aspirin  gr.  ii 

(0.125  Gm.)  at  2-hour  intervals  have  been  recommended. 
Discontinue  after  the  early  hours  (sthenic  period). 
Later  stages,  or  if  pain  is  severe,  codeine  phosphate  gr.  1/8-1/2 

(0.008-0.030  Gm.)  or  morphine  sulphate  gr.  1/12-1/4  (0.005- 

0.015  Gm.)  hypodermically. 

Headache. 

Relieve  congestion  by  adrenalin  chloride  (epinephrin)  1 :1000  solution 
three  minims  into  each  nostril. 

Nervousness. 

Bromides.  Potassium  bromide  or  triple  bromide  of  potassium,  sodium 
and  ammonium  gr.  xy  (1  Gm.)  in  %  glass  water  early  in  evening. 
Repeat  in  2-3  hours  if  needed. 


266  TREATMENT  OF  ACUTE  INFECTIOUS  DISEASES 

Early  in  the  disease  give  trional  gr.  xv  (1  Gm.)  in  warm  drink  or  in 
5  gr.  (0.33  Gm.)  capsules  early  in  the  evening, 

or  chloralamid  gr.  xx-xxx  (1.33-2  Gm.).  Repeat  in  2  hours  if  neces- 
sary, 

or  adalin,  gr.  v  (0.33  Gm.). 

In  more  persistent  insomnia,  barbital  (veronal)  gr.  v-viiss.  (0.33-0.50 
Gm.). 

Sodium  barbital  (medinal)  in  the  same  doses. 

Inmost  severe  cases,  codeine  phosphate  gr.  J^-J^  (0.0015-0.030  Gm.). 
Morphine  sulphate  gr.  1/4-1/8  (0.015-0.008  Gm.)  hypodermically. 
Repeat  if  necessary. 

Delirium  or  psychoses. 

Morphine  sulphate  gr.  J4  (0.015  Gm.)  hypodermically. 
Hyoscine  hydrobromide,  gr.  1/200-1/50  (0.0003-0.00045  Gm.). 
Avoid  noise,  talking,  visitors  in  room.    Keep  room  cool. 

Vomiting. 
Stop  all  food. 
Mustard  paste  (one  part  of  mustard  to  3-4  parts  of  flour)  apply  to 

pit  of  stomach. 
Cracked  ice  to  relieve  thirst. 
Food  resumed  as  milk  in  teaspoonful  doses. 

Diarrhea. 

Bismuth  subnitrate  gr.  xv~3i  (1^4  Gm.)  at  3-4  hour  intervals. 
Circulation. 

Early  digitalization  in  severe  cases.    (See  below.) 

Pneumonia. 

Blood  culture. 

Type  sputum  and  urine.    If  Type  I  pneumococcus,  give  serum. 
(See  Lobar  Pneumonia,  Chap.  IX.) 

Early  digitalization — 30  gr.  digitalis  in  the  course  of  2-3  days.  In 
severe  cases  in  the  course  of  36  hours.  When  circulation  is  en- 
dangered, intravenous  or  intramuscular  injections  of  strophanthin 
J£  to  1  mg.  (gr.  1/80-1/60).  Follow  at  once  by  digitalis.  (For  de- 
tailed discussion,  see  Pneumonia,  Chap.  IX.) 

Other  cardiac  stimulants — caffeine,  strychnine,  etc.  (See  Pneumonia, 
text  and  summary,  Chap.  IX.) 

Low  blood  pressure. 

Try  adrenalin  chloride  (epinephrin)  1:1000  m.  x-xv  (0.66-1  c.c.) 
at  2,  3,  4  hour  intervals  or  m.  ii-iii  (0.120-0.20  c.c.)  in  saline  very 
slowly  into  vein. 

Or  pituitrin  in  1  c.c.  (m.  xv)  doses  at  4-6  hour  intervals. 

Gentle  pressure  on  the  abdomen  as  by  a  binder. 

Venesection :  with  marked  cyanosis  and  deep  congestion  of  superficial 
vessels  of  skin  and  mucous  membranes  and  evidence  of  dilatation 
of  right  heart,  venesection  is  indicated;  but  moderate  amounts  of 
8-10  ounces  should  be  withdrawn  and  more  later  as  indicated. 


EPIDEMIC  INFLUENZA  267 

Pulmonary  edema. 

Strophanthin  intravenously.  Amorphous  official  preparation  1  mg. 
(gr.1/60),  crystalline  strpphanthin,  or  oubain,  1/2  mg.  (gr.  1/120). 
If  digitalis  has  been  administered  as  advised,  make  the  strophanthin 
one-half  the  above.  If  lesser  amounts  of  digitalis  have  been  taken 
give  %  the  above  dosage.  Repeat  in  four  hours  if  necessary. 

Adrenalin  chloride  (epinephrin)  1:1000  m.  xv  (1  c.c.)  intramuscularly 
every  15  minutes  for  6  doses.  May  follow  the  use  of  strophanthin  as 
given  above. 

Atropine  sulphate,  gr.  1/100  (0.0006  Gm.)  intramuscularly.  May  in- 
crease the  dose  to  gr.  1/75-1/50  (0.0009-0.0012  Gm.).  It  may  be 
repeated  in  four  hours. 

Oxygen  inhalations.    (See  text.) 

Cupping.    (See  text.) 

(For  technique,  see  Pneumonia,  Chap.  IX.) 

Cyanosis  and  Dyspnoea. 
Oxygen  inhalation. 

Cough. 

In  severe  types  codeine  phosphate,  gr.  J^-l  (0.015-0.060  Gm.)  by 

mouth  or  hypodermically  every  4-6  hours. 
Heroine  hydrochloride,  gr.  1/12-1/10  (0.005-0.006  Gm.)  by  mouth 

every  4-6  hours. 

Morphine  sulphate,  gr.  1/8-1/4  (0.008-0.015  Gm.). 
Cocaine  hydrochloride — spray   with   2   per   cent,   solution.     Have 

patient  breathe  deeply  and  use  only  two  or  three  jets  during  deep 

breathing.    After  an  interval  have  patient  expectorate  residue. 
If  from  bronchitis,  cup  chest.    (For  technique,  see  Pneumonia,  Chap. 

IX.)    In  children  use  a  mustard  paste  1 :8  or  1 :4. 
If  from  pleurisy — strap  chest  and  use  counterirritation  with  mustard 

1-4  to  1-8  according  to  age. 

Acidosis. 

Determined  by  laboratory  methods;  if  not  possible,  give  sodium 
bicarbonate  3i  (4  Gm.)  every  2  hours  until  urine  is  alkaline.  Two 
doses  should  be  sufficient  for  neutralization  in  normal  urine. 

Tympanites. 

Cut  down  on  or  eliminate  sugars. 

Administer  water  abundantly. 

Plain  or  turpentine  stupes.    (See  Typhoid  Fever,  Chap.  XIV.) 

Rectal  tubes. 

Enemata — plain  or  soap  suds,  turpentine,  milk  and  molasses,  or 

peppermint.    (For  technique,  see  Typhoid  Fever,  Chap.  XIV.) 
Pituitrin  m.  v-xv  (0.033-1  c.c.)  intramuscularly. 
Strychnine  sulphate  gr.  1/60-1/30  (0.001-0.002  Gm.). 

Serum  treatment. 

Convalescent  serum. 

(For  mode  of  obtaining,  see  text.) 


268  TREATMENT  OF  ACUTE  INFECTIOUS  DISEASES 

Dose,  120  c.c. 

Intervals  of  eight  hours  or  more  according  to  reaction. 

Administer  early. 

Mode  of  administration.    (See  Pneumonia,  Chap.  IX.) 

Desensitization  test  not  necessary. 

Pleurisy  and  empyema. 

Preliminary  aspiration,  and  operation  later  after  acute  stage  has 
passed,  unless  pressure  symptoms  demand  re-aspiration.     Wait 
until  pus  has  creamy  consistency. 
Lilienthal  method  of  aspiration. 

Trochar  and  cannula  with  Potain  apparatus  attached  by  rubber 
tube.  Insert  through  small  incision  between  ribs  in  most  depend- 
ent part  of  chest.  Patient  lies  on  edge  of  bed.  Air  entering  chest 
is  expelled  by  patient  straining  with  glottis  closed  until  bubbles 
cease  to  appear  from  the  end  of  the  rubber  tube  held  under 
water. 
Taylor's  method.  (See  Streptococcus  Pneumonia,  Chap.  X.) 

Abscess  of  lung. 

Treat  like  a  tuberculosis  patient — open  air  and  sunlight. 
Force  the  diet  to  approximate  3,000  calories  and  more  if  borne  well. 
Culture  sputum.    Use  vaccine  of  the  dominant  organism. 
Beginning  dose  should  be  small,  not  more  than  5-10  million. 
Dose  increased,  doubled  at  first,  and  administered  twice  a  week, 
the  increase  in  size  depending  on  reaction  and  results.     (For 
technique,  see  Index.) 

Guiacol  carbonate,  gr.  ii  (0.120  Gm.)  every  3  or  4  hours. 
Inhalations  of  equal  parts  of  alcohol  chloroform  and  creosote;  use 
ten  drops  on  a  zinc  inhaler  of  the  Robinson  type.    May  be  used  over 
long  period.     Especially  useful  in  cases  of  marked  fetor. 
Perforation  into  pleural  cavity  constitutes  an  empyema  and  demands 
treatment.    (See  above.) 

Emphysema. 
(See  text.) 

Tuberculosis. 

(See  text.) 

Heart  and  vessels. 

Failing  circulation.    (See  above  and  under  Pneumonia,  Chap.  IX.) 
Pericarditis.    (See  Acute  Rheumatic  Fever,  Chap.  III.) 
Arhythmias — bradycardia,  tachycardia,  sinus  arhythmia,  premature 
systoles  require  no  interference;  but  premature  systoles  in  con- 
valescence are  annoying;  hence,  eliminate  tea,  coffee,  and  tobacco. 
Bromides  gr.  x-xv  (0.066-1  Gm.)  Strychnine  sulphate,  gr.  1/60-1/30 
(0.001-0.002  Gm.)   three  times  a  day  given  after  bromides  or 
tincture  of  mix  vomica  m.  xv  (1  c.c.)  may  be  given  with  bromides, 
gr.  x  (0.66  Gm.)  three  times  a  day. 


EPIDEMIC  INFLUENZA  269 

Tachycardia. 

(For  discussion,  see  text.) 
Bradycardia. 

Requires  no  interference,  even  when  due  to  heart  block;  it  usually 
disappears  itself. 

Auricular  fibrillation  may  disappear,  but  usually  is  permanent. 
If  the  latter,  treated  as  auricular  fibrillation  under  other  cir- 
cumstances. 
Phlebitis. 

(See  Typhoid  Fever,  Chap.  XIV.) 
Nephritis. 

Rare  occurrence.    (See  Scarlet  Fever,  Chap.  XVII.) 
Pyelonephritis. 

Drainage  by  catheter. 

Pelvic  lavage. 

Urinary  antiseptics. 

Non-irritating  diet. 

Colon  irrigations. 
Perinephritic  abscess. 

Incision  and  drainage. 
Epididymitis,  seminal  vesiculitis  and  prostatic  abscess. 

(See  works  on  genito-urinary  diseases.) 

Meningitis. 

(See  text.    Treat  as  in  cerebrospinal  meningitis.    See  Chap.  XXV.) 

Meningism. 

Lumbar  puncture. 
(See  Chap.  XXV.) 

Encephalitis  lethargica. 
(See  Chap.  XIII.) 

Mental  disturbances. 

(Consult  text.) 

Depressed  patients  should  be  carefully  watched  lest  suicide  be  at- 
tempted. 
Push  food. 

Continued  rest  followed  by  massage.    Graduated  exercises. 
Fresh  air. 

Attention  to  bowels. 
In  cases  of  excitement,  the  continuous  bath. 

Abdominal  symptoms. 
(See  text.) 

Convalescence. 

Period  of  convalescence  should  not  be  hastened. 
Confine  to  bed  for  two  days  after  temperature  is  normal.    Do  not 
allow  resumption  of  duties  for  one  week. 


270  TREATMENT  OF  ACUTE  INFECTIOUS  DISEASES 

After  severe  cases  or  a  pneumonia,  keep  in  bed  ten  days  after  tempera- 
ture is  normal  and  physical  signs  have  disappeared;  get  about 
gradually  and  do  not  resume  duties  for  several  weeks. 
Change  of  environment  before  this  desirable. 

Do  not  discharge  until  he  feels  and  looks  fit, 'blood  pressure  is  normal 
and  signs  of  cardiac  incompetency  absent. 

Fresh  air,  sunlight,  good  food. 

Graduated  exercises. 

Tonic,  strychnine  sulphate,  gr.  1/60-1/30  (0.001-0.002  Gm.)  or: 

3 

Sodii  Glycerophosphatis 

Tr.  Nucis  Vomicse aalO        (Siiss.) 

Aq.,  q.  s.  ad 60        (gii) 

M.  et  S.    One  teaspoonful  (5i)  in  water  three  times  a  day  after  meals. 

Prophylaxis. 

Avoid  those  infected. 

Avoid  fatigue. 

Avoid  undue  exposure,  remaining  in  wet  clothes. 

Avoid  crowded  public  conveyances  and  public  places. 

Talking,  laughing,  sneezing  and  coughing  of  the  infected  spreads 

the  diseases. 

Avoid  contact  with  articles  used  by  infected  individual. 
Kissing,    promiscuous   hand-shaking,    using   public   toilet    articles, 

half-cleaned  eating  utensils  and  public  eating  places  are  a  menace. 

Vaccines. 

(See  text.) 

Otitis  media. 

(See  text  and  Scarlet  Fever,  Chap.  XVII.) 

Parotitis. 

(See  text.) 

(See  Mumps,  Chap.  XXIII.) 

Abscess  of  the  muscles. 
Immobilization. 
Wet  dressings. 
Later  incision  and  drainage. 


CHAPTER  XIII 

ENCEPHALITIS  LETHARGICA 

FOLLOWING  upon  the  great  epidemic  of  influenza  of  1917  and  1918 
appeared  a  lesser  epidemic  characterized  by  a  widespread  focal  inflam- 
mation of  the  cerebrospinal  nervous  system.  Similar  epidemics  have 
been  noted  before  and  their  relationship  to  influenza  commented  on. 
An  identical  causative  organism  has  not  been  determined,  but  able 
epidemiologists,  tracing  the  sequelae  and  character  of  the  great  plagues 
of  Europe  since  medieval  time,  have  been  so  impressed  with  the  re- 
lationship noted  above  as  to  express  their  belief  that  they  were  but 
different  expressions  of  the  same  infection  (Crookshank) .  Others  suggest 
that  influenza  renders  the  patient  susceptible  to  invasion  by  this  virus 
or  that  the  conditions  favoring  one,  favor  the  other.  Others  have  sought 
to  argue  a  relationship  between  this  disease  and  poliomyelitis  (Heine- 
Medin  Disease),  attributing  the  difference  to  different  strains  of  the  same 
organism.  But  all  this  is  mere  conjecture.  Up  to  the  present  time  the 
nature  of  the  virus  is  unknown.  The  entrance  of  the  virus  is  probably 
through  the  nose. 

The  name  that  has  come  into  very  general  use  was  adopted  because 
of  the  drowsy  state  shown  by  many  of  the  early  cases  that  won  for  the 
disease  the  popular  appelation  of  Sleeping  Sickness,  which,  of  course, 
has  no  relationship  to  the  African  disease  of  that  name.  The  name  is 
inadequate,  for  many  of  the  cases  show  no  signs  of  lethargy,  but  depend- 
ing on  the  site  of  the  lesion  simulate  a  variety  of  diseases  of  the  central 
nervous  system  and  especially  the  polio-encephalitic  forms  of  the  Heine- 
Medin  Disease. 

The  Pathology.  The  lesion  is  a  congestion  of  the  meninges 
and  small  hemorrhages  into  both  white  and  gray  matter.  These  are 
especially  common  at  the  base.  Microscopically  there  is  cellular  in- 
filtration about  the  vessels.  It  occurs  in  any  age,  even  in  infancy. 

Symptomatology.  The  onset  may  be  gradual  or  fairly  abrupt 
and  the  apparent  somnolence,  drowsiness  or  lethargy  one  of  the  most 
characteristic  features. 

In  the  first  case  I  saw,  this  gradually  increasing  apathy  that  would 
cause  the  patient  to  interrupt  his  effort,  as  if  in  the  act  of  lacing  his 
shoes,  he  had  fallen  asleep,  was  very  striking  and  the  period  to  the  full 
development  when  the  patient's  mask-like  face  looked  like  a  Parkinson's 


272  TREATMENT  OF  ACUTE  INFECTIOUS  DISEASES 

Disease,  was  very  slow.  In  the  second  case,  deep  lethargy  came  on 
quickly  after  striking  the  head  against  a  heavy  piece  of  machinery  and 
was  thought  at  first  to  be  a  fracture  of  the  base  of  the  skull. 

The  apathy  varies  hi  degree  from  mere  drowsiness  to  what  appears 
to  be  a  complete  coma  as  in  the  second  case  listed,  and  yet  the  lethargy, 
while  in  part  real,  is  largely  apparent  and  our  surprise  was  great  in  this 
early  case  to  have  the  patient  addres?  us  out  of  his  coma  and  tell  us 
what  had  happened  during  the  ten  days  of  what  we  deemed  complete 
unconsciousness,  telling  the  names  of  his  nurses,  the  internes  and  attend- 
ing physicians.  It  is  not  hard  to  rouse  a  patient  from  what  seems  deep 
stupor  and  elicit  intelligent  responses;  but  the  voice  is  monotonous  and 
nasal  and  the  speech  slow.  These  cases  resembled  Parkinson's  Disease 
in  their  perfectly  expressionless  faces;  the  eyelids  droop  so  that  the  ap- 
pearance of  coma  is  heightened.  The  limbs  are  somewhat  rigid  and 
take  and  retain  positions  into  which  they  are  put,  a  veritable  catatonia. 
Extended  legs  and  half  flexed  arms  held  persistently  in  these  positions 
was  a  peculiar  feature. 

Sometimes  mental  depression  is  obvious  and  delirium  may  occur. 
Paradoxical  it  seems  to  have  a  patient  suffer  from  insomnia,  who  seems 
to  be  sleeping  continuously;  but  this  is  not  uncommon  and  though  he 
may  be  drowsy  and  quiet  by  day,  sleeplessness  and  restlessness  harass 
him  by  night. 

Dizziness  is  a  common  symptom  and  headache  is  complained  of. 

Fever  is  not  a  striking  feature  of  the  disease,  but  perhaps  is  always 
present  at  some  period  of  the  disease  though  it  may  be  overlooked.  It 
lasts  only  a  few  days,  but  may  continue  for  two  to  three  weeks.  It  is 
rarely  more  than  100°  F.  to  102°  F.  but  on  occasion  rises  to  104°  F.  to 
105°  F. 

The  blood  count  shows  as  a  rule  a  slight  white  cell  increase  though 
it  may  be  normal,  but  more  marked  leucocytosis  and  polynucleosis  have 
been  reported. 

The  spinal  cord  fluid  is  under  increased  pressure,  shows  an  increase 
of  globulin  and  a  pleocytosis  of  10  to  100  of  lymphocytic  type.  Focal 
symptoms  are  very  varied  and  lend  to  a  great  number  of  types.  It  is 
well,  however,  to  first  consider  those  that  are  fairly  constant  in  all  cases. 
These  are  affections  of  the  nuclei  and  roots  of  nerves  supplying  the 
muscles  to  the  eye  (3d,  4th,  and  6th)  causing  external  and  internal 
ophthalmoplegia  and  ptosis.  Opthalmoplegia  occurs  in  some  75  per  cent, 
of  cases  and  ptosis  is  the  most  common  of  the  occular  disturbances.  This 
causes  the  almost  constant  symptoms  of  drooping  lids,  usually  bilateral, 
diploplia,  blurring  of  vision  and  strabismus,  inequalities  hi  pupils  and 
disturbance  of  reaction  to  light.  Nystagmus  is  not  unusual.  But  while 


ENCEPHALITIS  LETHARGICA  273 

the  oculi  motores  are  so  commonly  affected  as  to  offer  characteristic 
features  to  the  disease,  the  other  cranial  nerve  nuclei  by  no  means 
escape  and  afford  variety  to  the  picture.  The  involvement  of  the  motor 
nuclei  of  the  5th,  is  shown  by  weakening  of  the  action  of  the  masseters, 
so  that  when  the  patient  is  asked  to  clinch  the  jaws  the  muscle  masses 
fail  their  characteristic  hardness;  that  of  the  7th  is  shown  by  varying 
degrees  of  facial  palsy;  of  the  8th  by  deafness  and  vestibular  disturb- 
ance— dizziness;  of  the  9th  by  difficulty  in  swallowing;  of  the  10th,  by 
resulting  tachycardia;  of  the  12th,  by  involvement  of  the  tongue. 

The  ganglia  at  the  base  of  the  brain  may  be  implicated.  The  mask- 
like  expression  may  be  due  in  part,  at  least,  to  the  involvement  of  the 
globus  pallidus  (Ramsay  Hunt)  and  I  have  witnessed  in  a  number  of 
cases  twitching  of  groups  of  muscle  fibres  in  the  face,  trunk  and  limbs 
corresponding  to  the  picture  of  para-myoclonus  multiplex  and  occa- 
sionally coarser  quick  rhythmic  movements  like  electrical  chorea  that 
may  be  due  to  lesions  hi  the  thalmic  or  other  basal  ganglia. 

To  add  to  the  complexity  and  variety  of  the  picture  the  cortex  may  be 
involved  not  only  to  produce  the  general  symptoms  of  drowsiness,  de- 
pression or  delirium,  but  also  by  focal  lesions,  causing  varied  paralyses, 
hemiplegias,  monoplegias,  motor  or  sensory  aphasias,  amnesias;  or  sen- 
sory areas  are  affected  with  the  production  of  anesthesias  or  lesions  in 
the  cerebellum  or  its  peduncles  give  rise  to  ataxias.  Meningeal  symp- 
toms more  rarely  occur,  but  I  have  seen  them  fairly  pronounced  with 
stiff  neck  and  Kernig's  sign  and  headache.  Nor  does  the  spinal  cord 
always  escape  and  there  seems  to  be  a  distinct  polyneuritic  type. 

To  one  reading  of  the  multiplicity  of  neurological  manifestations 
in  this  disease,  it  would  seem  as  if  a  diagnosis  was  hopeless;  but  it  is  sur- 
prising how  soon  a  contact  with  these  cases  elicits  a  recognition  of  the 
symptom  complex  as  something  very  definite.  Of  course,  the  knowl- 
edge of  a  prevailing  epidemic  makes  a  diagnosis  fairly  sure  that  would 
be  more  than  hazardous  in  a  sporadic  case. 

The  course  of  the  disease  varies  tremendously,  from  the  fulminating, 
in  which  death  is  a  matter  of  hours  or  days  to  those  that  last  for  many 
months.  The  stupor  usually  lasts  two  to  five  weeks.  Relapses  do  not 
seem  to  be  common,  but  I  have  seen  one  such  case. 

One  should  remember  in  giving  a  prognosis  that  recovery  is  the  rule 
even  when  the  patient  seems  desperately  ill.  If  the  patient  survives  the 
first  few  days,  in  spite  of  profound  stupor  I  am  inclined  to  give 
a  good  prognosis  as  to  life  and  a  fair  one  as  to  complete  recovery. 
The  mortality  varies  in  different  series,  but  it  averages  about  10 
per  cent. 

Sequelae.     Considering   the    extent    of    damage   done    in    many 


274  TREATMENT  OF  ACUTE  INFECTIOUS  DISEASES 

cases,  the  residual  disturbance  is  remarkably  little.  One  almost  gets 
in  the  habit  of  giving  favorable  prognoses.  However,  mental  disturb- 
ance in  children,  certain  degrees  of  imbecility,  and  cranial  and  spinal 
paralysis  have  persisted. 

Treatment.  There  is  no  specific  treatment.  Good  nursing 
and  the  relief  of  symptoms  constitute  the  sum  total  of  therapy*  The 
disease  is  long  drawn  out  in  many  instances,  the  patient  completely 
helpless  and  the  demands  made  on  watchful  and  faithful  nursing  are 
many  and  exacting. 

Room.  A  cheerful  room,  well  ventilated,  with  near  access  to 
the  bathroom,  chosen  if  possible  in  the  quietest  part  of  the  house,  is 
to  be  selected.  In  some  instances  photophobia  requires  some  darkening 
of  the  room.  Many  patients  are  irritable;  indeed,  some  clinicians  recog- 
nize an  irritable  type  of  the  disease.  There  is  often  hyperesthesia  and 
in  some  cases  marked  headache.  Noise  causes  great  discomfort  and  the 
patient  requires  the  gentlest  handling. 

Bed  should  be  of  the  hospital  type  or  at  the  most  three-quarter, 
with  a  good  woven  wire  spring  and  a  firm  hair  mattress.  The  mat- 
tress should  be  protected  by  a  rubber  sheet  and  draw  sheet.  (For  details 
see  Chap.  IX.)  The  sheets  kept  smooth  to  prevent  irritation  of  the 
skin  or  bed  sores. 

Care  of  the  Body.  The  patient  should  have  a  warm  bath  with 
castile  soap  and  water  each  day.  Especial  attention  should  be  given  to 
the  mouth,  teeth  and  nose  and  to  the  genitals  and  buttocks.  (For  details, 
see  Pneumonia,  Chap.  IX.) 

The  Bowels  should  be  moved  by  enemata  or  by  readily  swal- 
lowed laxatives,  such  as  cascara,  phenolphthalein,  pills  containing  aloin, 
or  liquid  paraffin.  Constipation  often  obtains  and  must  not  be  neglected. 

Diet.  Except  in  cases  suffering  from  dysphagia,  food  is  taken 
even  by  those  that  seem  very  lethargic.  The  diet  should  approximate 
caloric  needs,  some  3,000  a  day  and  the  articles  may  be  chosen  from  such 
a  list  as  is  given  under  Typhoid  Fever  (Chap.  XIV).  In  dysphagia  or 
deep  coma,  feeding  by  nasal  tube  may  be  necessary.  (See  Diphtheria, 
Chap.  XVIII.)  Water  or  fruit  drinks  or  alkaline  waters  should  be 
given  freely  and,  as  the  patient's  apathy  prevents  his  expressing  his 
needs,  it  should  be  given  to  him  up  to  the  amount  of  two  quarts  or  more 
a  day. 

Headache  and  pains.  Headache  may  be  relieved  by  the  use 
of  the  ice  bag.  It  and  general  aches  and  pains  are  to  be  met  by  the 
administration  of  aspirin  (acetylsalicylic  acid)  in  gr.  v-gr.  x  (0.33-0.66 
Gm.)  doses  at  two-hour  intervals,  if  needed;  but  coal  tars  should  be  used 
with  caution,  if  at  all.  Codeine  phosphate  in  doses  of  Gr.  1/8-gr.  1/4 


ENCEPHALITIS  LETHARGICA  275 

(0.008-0.015  Gm.)  may  be  given  by  mouth  or  subcutaneously  but 
morphine  should  be  used  with  great  care. 

The  extent  and  degree  of  cerebral  and  nuclear  involvement,  depression 
and  lethargy  on  the  one  hand  or  irritability,  insomnia  or  delirium  on  the 
other  will  modify  our  usage  of  drugs  in  accordance  with  their  known 
pharmacological  and  toxic  properties. 

Headaches  and  pains  in  chest  and  extremities  may  be  relieved  by 
lumbar  puncture  and  the  measure  has  come  into  fairly  extensive  use. 

Lumbar  Puncture  not  only  relieves  the  headache  and  pains, 
especially  if  the  spinal  fluid  is  under  pressure,  but  it  often  lessens  the 
stupor  and  other  symptoms  and  may  be  repeated  with  benefit.  The 
procedure  is  usually  done  early  for  diagnostic  purposes  and  demonstrates 
its  ameliorative  effect  on  the  symptoms  on  that  occasion. 

Hyperesthesia  and  paresthesia  as  well  as  pain  are  relieved  by 
warmth,  and  the  discomfort  of  pressure  and  irritation  by  clothes  is 
relieved  by  raising  them  by  frames. 

Irritability  and  restlessness  may  be  relieved  by  bromides  in 
doses  of  gr.  x-xxx  (0.66-2  Gm.)  or  by  chloral  hydrate  in  tentative  doses 
beginning  with  gr.  v  (0.33  Gm.).  This  would  be  indicated  rather  in  those 
cases  complicated  by  sleeplessness. 

Insomnia.  Quiet,  fresh  air,  properly  arranged  bed,  toilet  for 
the  night,  bromides  and  small  doses  of  chloral  in  the  restless  may  be  used. 
Codeine  phosphate  gr.  1/8-gr.  1/4  (0.008-0.015  Gm.)  may  be  given  by 
hypodermic  method,  but  morphine  had  better  not  be  used. 

Fever  is  not  a  marked  feature,  but  if  a  source  of  annoyance, 
relief  may  be  afforded  by  cool  sponging. 

Convalescence  is  long.  Fresh  air,  good  food,  massage,  hydro- 
therapy  and  other  measures  to  meet  residual  paralyses  exercise  the 
ingenuity  of  the  practitioner. 

SUMMARY 

Treatment.    There  is  no  specific  treatment. 

Room. 

Well  ventilated. 

Access  to  bathroom. 

In  quiet  part  of  house. 

Sunlight  unless  photophobia  indicates  darkening  the  room. 

Bed. 

Hospital  type  preferred. 
Half  or  three-quarters. 
Woven  wire  springs. 


276  TREATMENT  OF  ACUTE  INFECTIOUS  DISEASES 

Care  of  body. 

Daily  warm  baths,  with  castile  soap  and  water. 
Mouth,  teeth,  nose,  genitals.    (See  Pneumonia,  Chap.  IX.) 

Bowels.        '*f~ 
Enemata. 

If  patient   swallows   readily,    cascara,   phenolthalein,   aloin,   liquid 
paraffin  in  suitable  doses. 

Diet. 

If  effort  is  made,  food  is  taken  by  those  that  seem  very  lethargic. 
Try  to  approximate  the  caloric  needs  of  3,000  calories. 
(For  items  of  diet,  see  Typhoid  Fever,  Chap.  XIV.) 
In  dysphagia  or  deep  coma  nasal  feeding  may  be  necessary. 
(See  Diphtheria,  Chap.  XVIII.) 

Drinks. 
Water,  alkaline  water,  fruit  juices,  orangeade,  lemonade,  may  be 

given  freely. 
Try  to  approximate  two  quarts  or  more  a  day. 

Pains  and  headache. 
Ice  bag  to  head. 

Aspirin  (acetylsalicylic  acid),  gr.  v-x  (0.035-0.066  Gm.)  if  needed. 
Avoid  coal-tar  preparations. 

Codeine  phosphate,  gr.  1/8-1/4  (0.008-0.015  Gm.). 
Lumbar  puncture,  besides  diagnostic  value,  relieves  headache  and 
pains  in  extremities  and  stupor. 

Hyperesthesia  and  paresthesia. 
Warmth. 
Raising  of  bed  clothes  from  the  skin  by  the  use  of  frames. 

Irritability  and  restlessness. 
Bromides,  gr.  x-xxx  (0.66^-0.2  Gm.). 
Chloral  hydrate  in  tentative  doses  beginning  with  gr.  v  (0.33  Gm.). 

Insomnia. 

Quiet,  fresh  air,  attention  to  bed  and  toilet  for  the  night. 
Bromides,  gr.  xv  (1.0  Gm.)  early  in  evening.    Repeat  if  needed. 
Chloral  hydrate,  gr.  v-x  (0.33-0.66  Gm.)  early  in  the  evening. 
Codeine  phosphate,  gr.  1/8-1/4  (0.008-0.015) 'hypodermically. 

Fever. 

Rarely  needs  treatment. 
If  annoying,  cool  sponges. 

Convalescence. 
Long  drawn  out. 
Fresh  air. 
Good  food. 
Massage. 
Residual  paralysis  treated  as  under  other  circumstances. 


CHAPTER  XIV 

TYPHOID  AND  PARATYPHOID  FEVERS 

TYPHOID   FEVER 

Etiology.  Typhoid  fever,  which  is  one  of  the  commonest  dis- 
eases in  our  experience,  but  less  common  than  in  the  experience  of  our 
medical  fathers,  thanks  to  the  interest  elicited  by  the  work  of  the  re- 
search scholar  and  an  awakened  sense  of  civic  responsibility,  is  due  to 
the  invasion  of  the  body  by  a  definite  bacterium,  Bacillus  typhosus 
of  Eberth.  The  gross  lesions  are  referable  to  the  intestinal  canal  but 
they  are  to  be  looked  upon  merely  as  local  expressions  of  a  general 
infection.  This  is  an  important  therapeutic  concept,  as  it  directs  our 
attention  to  the  individual  as  a  whole  and  spares  us  useless  effort  to 
medicate  the  intestinal  canal,  in  the  hope  of  curing  the  disease.  The 
mortality  varies  in  different  epidemics  and  varies  in  private  and 
hospital  practice,  but  on  the  whole  is  in  the  neighborhood  of  15  per  cent. 

The  mortality  has  been  greatly  lessened  in  the  Army  and  Navy  where 
prophylactic  vaccination  is  compulsory. 

Pathology.  Typhoid  fever  is  a  general  infection,  but  its  most 
marked  expressions  are  to  be  found  in  the  Peyer's  patches  and  solitary 
follicles  of  the  intestine,  which  are  greatly  infiltrated  and  swollen  and 
may  ulcerate  with  hemorrhage  and  perforation. 

Symptomatology.  This  must  be  sought  in  its  details  in  stand- 
ard text-books  of  medicine.  Briefly,  its  onset  is  usually  insidious  after  an 
incubation  of  10-14  days  with  a  temperature  increasing  daily  throughout 
the  second  week,  falling  in  the  morning  in  the  third  week  and  falling 
night  and  morning  throughout  the  fourth  week  until  normal  is  reached. 
Often  subjective  symptoms  are  curiously  slight  compared  with  the  degree 
of  temperature,  which  runs  at  103°-104°  F.  during  its  height.  Slow 
pulse,  leucopenia,  rose  spots,  enlarged  spleen,  tympanites,  constipation 
are  all  characteristics;  stupor,  delirium  and  subsultus  tendinum  in 
severe  cases.  Hemorrhages  from  intestinal  ulceration  and  perforation 
are  dreaded  complications.  Relapses  are  not  uncommon. 

Tympanites  may  be  due  to  any  of  the  above  sources;  but  milk  sugar 
must  be  particularly  suspected. 

Diarrhea  is  more  commonly  caused  by  an  excess  of  fat  and  cream,  but 
may  be  due  to  lactose. 


278  TREATMENT  OF  ACUTE  INFECTIOUS  DISEASES 

Certainly,  patients  sufficiently  fed,  in  my  experience,  look  less  toxic, 
are  more  content  and  emerge  from  their  illness  less  wasted.  The  nervous 
manifestations  seem  to  me  less  pronounced  and  my  impression  is  that 
the  common- complication  of  hemorrhage  and  perforation  are  less  fre- 
quently met  with.  Coleman's  figures  would  show  hemorrhages  to  be  no 
less  frequent,  but  decidedly  less  fatal  and  perforations  more-rare.  He 
claims  a  drop  in  mortality  from  17.6  per  cent,  to  8.10  per  cent,  under 
high  caloric  feeding. 

Therapy.  We  are  dealing  with  a  self-limited  disease,  the  cure 
of  which  depends  on  the  elaboration  of  specific  bodies  by  the  tissue  cells 
of  the  patient,  a  result  we  have  not  yet  been  able  to  duplicate  in  the 
laboratory,  but  which  we  can  influence  by  the  use  of  vaccines.  This 
does  not  mean  that  we  cannot  further  modify  the  course  of  the  disease. 
On  the  contrary,  a  considerable  fall  in  mortality  has  come  about  as  the 
result  of  skilled  care,  conscientious  watchfulness,  competent  nursing 
and  the  application  of  definite  measures  to  the  relief  of  symptoms  and 
complications. 

Rest.  It  would  seem  almost  superfluous  in  a  disease  of  such 
import  as  typhoid  fever  to  insist  on  rest,  but  it  must  be  remembered 
that  the  onset  is  slow,  and  in  mild  cases,  or  what  at  the  beginning  prom- 
ises to  be  a  mild  case,  the  patient  is  prone  to  look  upon  it  as  an  indisposi- 
tion, and  the  physician  may  be  uncertain  of  his  diagnosis,  and  in  the 
meantime  the  patient  is  on  his  feet,  perhaps  attempting  to  attend  to 
his  business,  or  at  least  protesting  against  the  bed.  These  cases  are  the 
so-called  "  walking  typhoids."  Statistics  have  shown  that  these  cases  do 
not  do  as  well  as  those  receiving  attention  promptly,  and  it  is  probable 
that  what  might  have  been  a  mild  typhoid  attack  has  been  converted, 
by  lowering  the  resistance  of  the  patient,  into  a  severe" or  fatal  case. 

Where,  then,  suspicion  is  aroused  as  to  the  possibility  of  typhoid 
fever,  the  patient  should  not  be  permitted  to  waste  his  precious  strength 
while  one  is  awaiting  the  development  of  diagnostic  symptoms  or  the 
result  of  blood  examinations.  He  should  be  put  to  bed  at  once  and 
prepared  for  what  is  likely  to  be  a  long  siege.  Real  rest  can  be  obtained 
only  by  careful  and  competent  nursing,  by  the  exclusion  from  the  sick- 
room of  all  business  cares  and  causes  for  anxiety,  and  refusal  to  make  the 
sickroom  a  reception  room  for  solicitous  friends. 

The  patient  is  not  to  leave  the  bed  to  go  to  the  toilet,  or  even  to  use 
a  commode,  but  the  bed  pan  is  to  be  insisted  on.  This  trouble  comes  in 
the  early  days  of  the  fever.  It  will  be  a  source  of  argumentation  and 
contention,  but  one's  dictum  must  be  firm,  backed  up  by  a  few  words  of 
explanation.  The  need  for  rest,  the  need  of  sparing  the  tissues  useless 
oxidation,  is  emphasized  by  the  length  of  the  disease. 


TYPHOID  FEVER  279 

Bed.  While  remembering  to  conserve  the  strength  of  the  pa- 
tient, it  must  not  be  forgotten  that  the  strength  of  the  attendant  ought 
to  be  economized,  and  in  no  way  can  this  be  done  to  better  advantage 
than  in  selecting  a  bed  on  which  the  patient  can  be  readily  handled. 
The  ideal  bed  is  the  half-bed,  or  single  bed,  of  a  convenient  height,  with 
strong  woven  wire  springs  and  a  firm  springy  mattress.  A  folded  blanket 
will  render  the  surface  smooth.  Over  the  blanket,  is  to  be  placed  a 
sheet,  rubber  sheet,  and  a  draw  sheet.  Sheets  should  be  drawn  smooth, 
for  freedom  from  wrinkles  and  dryness  and  cleanliness  are  great  factors  in 
preventing  discomfort,  and,  in  very  sick  patients,  the  formation  of  bed- 
sores. Over  the  patient  a  sheet  and  a  light  blanket  is  sufficient;  and  one 
low  pillow,  not  too  soft,  makes  for  comfort.  The  upper  sheet  should  not 
be  drawn  too  tightly  over  the  feet  of  the  patient,  as  is  often  done  to 
improve  the  appearance  of  the  bed,  to  the  patient's  great  discomfort. 

Room.  The  best  room  is  the  largest  room,  with  the  amount 
of  light  most  gratifying  to  the  patient;  with  sunshine  in  the  colder 
months,  and  shade  in  the  summer  months.  It  should  be  well  ventilated 
and  free  from  encumbrances.  A  hardwood  floor  is  best.  If  there  are 
carpets,  they  should  be  protected  in  the  vicinity  of  the  bed,  in  consider- 
ation of  contamination  with  secretions,  which  may  occur  in  the  ordinary 
handling  of  the  patient.  It  is  very  desirable  to  have  a  bathroom  near  at 
hand,  for  the  convenience  of  disinfecting  and  disposing  of  secretions,  as 
well  as  for  facilitating  hydrotherapeutic  measures.  The  room  and  bath- 
room should  be  screened  against  flies,  whose  contamination  with  the  se- 
cretions scatter  the  infection. 

If  there  is  a  balcony  or  piazza  that  may  be  approached  from  the 
room,  it  meets  a  great  desideratum,  for  in  summer  the  patient  ought 
to  be  kept  out  of  doors,  and  in  winter  I  am  convinced  of  the  value  of  cold 
air  in  improving  the  nervous  manifestations  and  general  condition  of  the 
patients.  I  believe  we  shall  use  the  open-air  treatment  for  all  infectious 
fevers  with  vast  benefit. 

The  bed  should  be  prepared  by  placing  a  blanket  on  the  wire  springs, 
and  on  this  a  rubber  sheet,  each  extending  well  below  and  on  either  side 
of  the  bed.  On  these  is  placed  the  mattress,  on  which  the  bed  is  made  as 
usual.  Over  the  mattress  and  its  coverings  the  blanket  and  rubber  sheet 
are  now  folded  like  an  envelope,  thus  preventing  the  entrance  of  air  under 
the  clothes.  A  hood  is  worn  by  the  patient  and  a  hot-water  bottle  placed 
at  the  feet;  the  nurses  are  dressed  for  out  of  doors. 

When  there  is  diarrhea  and  incontinence  of  the  bowel  or  bladder,  then 
more  constant  attention  to  the  bed  does  not  make  the  open-air  treatment 
feasible.  If  the  patient  is  very  sick  or  is  delirious,  a  nurse  should  be  in 
the  room  day  and  night,  as  self-destruction  has  occurred  in  this  condition. 


280  TREATMENT  OF  ACUTE  INFECTIOUS  DISEASES 

Care  of  the  Body.  If  a  properly  trained  nurse  is  in  attend- 
ance, she  will  exercise  all  those  niceties  of  her  profession  with  reference 
to  the  care  of  the  patient's  body  and  comfort,  which  will  usually  improve 
on  one's  own  suggestions,  but  it  is  unjust  to  the  patient  to  take  that  for 
granted,  and  a  quiet  survey  of  the  situation  and  inquiry  into  the  methods 
used  is  proper.  However,  all  nurses  are  not  properly  trained,  and  all 
patients  cannot  afford  the  attendance  of  a  nurse.  Under  these  circum- 
stances, one  must  know  what  should  be  done;  one  should  write  out 
explicitly  what  is  to  be  done,  and  then  see  that  the  instructions  are 
comprehended  and  successfully  carried  out. 

The  state  of  the  patient's  mouth  requires  constant  attention,  lest, 
from  a  foul  condition,  it  become  the  source  of  infection  of  the  mucous 
membranes  and  their  lymphatic  supply,  the  tonsils,  the  ears,  and  the 
lungs;  and,  upsetting  the  stomach,  destroys  the  appetite.  The  teeth 
should  be  brushed  two  or  three  times  a  day.  The  mouth  should  be 
rinsed  with  water  or  boric  acid  solution  (2  per  cent,  to  4  per  cent.),  or 
one  of  many  mild  alkaline  and  antiseptic  washes,  after  each  feeding. 

Tongue.  If  there  is  a  heavy  coat  on  the  tongue,  such  may 
be  removed  by  careful  scraping  with  the  edge  of  a  whalebone.  Especial 
care  must  be  taken  to  get  at  the  back  of  the  tongue  and  remove  thick 
mucus  from  the  throat.  The  cotton  swab  on  a  toothpick  is  a  ready 
means  of  getting  at  the  dead  spaces  in  the  mouth,  where  food  may 
collect  and  decompose. 

If  there  is  much  sordes,  and  there  are  fissures,  a  mild  antiseptic  con- 
taining phenol  is  of  value.  Here  is  one  recommended  for  the  purpose : 

s 

Phenol  Solution,  1  to  20, 

Glycerin aa  5 i  30. 00 

Boric  Acid,  saturated  solution 5  viii          240. 00 

S.    To  be  used  as  a  mouth  wash. 

Bits  of  cracked  ice  are  grateful,  and  the  condition  is  much  relieved  if 
the  patient  gets  enough  water  to  drink.  The  nose  is  to  be  kept  clear  by 
the  use  of  olive  oil  on  a  swab,  to  soften  dried  masses,  and  cleansing  with 
boric  acid  solution  or  mild  alkaline  solutions.  Whether  hydrothera- 
peutic  measures  are  pursued  or  not,  the  body  is  to  have  a  cleansing  bath 
with  warm  water  and  soap  and  the  sponge. 

Bedsores.  The  formation  of  bedsores  is  the  bete  noire  of  a  good 
nurse,  and  this  she  avoids  by  constant  care  of  the  skin.  Moisture 
about  the  buttocks  is  quickly  removed,  the  parts  sponged  with  alcohol 
or  alcohol  and  water,  equal  parts,  and,  if  the  buttocks  have  been  much 
soiled,  with  a  mild  antiseptic  solution — phenol,  1  to  40,  for  example.  If 
pressure  has  been  long  continued,  the  skin  is  rubbed  to  improve  the 


TYPHOID  FEVER  281 

circulation  in  the  part.  The  parts  are  then  dusted  abundantly  with 
a  drying  powder,  like  any  of  the  talcum  powders  used  for  toilet  purposes. 
The  skin  of  the  whole  back  is  treated  in  this  way.  Especial  attention  is 
paid  to  the  sacrum,  the  anus,  the  buttocks,  and  the  heels.  The  position 
of  the  patient  should  be  frequently  changed,  not  only  to  avoid  bedsores, 
but  to  lessen  the  chance  of  hypostasis  in  the  lungs. 

If  sores  are  threatening,  rings  are  wsed  to  take  the  pressure  off,  but 
unless  used  intelligently,  they  may  be  more  annoying  than  useful.  If 
bedsores  develop,  it  may  be  imperative  to  use  a  water-bed  or  air-bed. 
The  excoriated  skin  may  be  covered  with  a  drying  powder,  like  aristol, 
or  a  bland  ointment,  like  zinc  oxide  ointment.  If  more  serious  sores 
appear,  they  are  to  be  treated  on  surgical  principles. 

At  certain  times  and  in  certain  places  flies  are  a  great  annoyance 
to  the  patient,  and,  not  only  that,  but  a  very  real  danger  to  other  mem- 
bers of  the  family  or  vicinity,  by  their  well-known  ability  to  carry  infec- 
tion from  the  patient  to  the  food  or  drink  of  those  about  him.  Under 
such  circumstances,  screens  in  the  room  and  over  the  patient  are  all- 
important. 

This  leads  naturally  to  a  consideration  of  the  disposition  of  the  secre- 
tions and  disinfection  of  the  patient's  clothes  and  utensils. 

Disinfection.  The  stools,  the  urine,  the  clothes,  the  utensils, 
the  bath  water,  the  sputum,  and  the  vomit  us  have  all  to  be  taken  into 
consideration.  Stools  may  be  disinfected  by  1  to  20  phenol.  At 
least  twice  the  volume  of  the  stool  should  be  used,  the  stool  well  broken 
up  and  allowed  to  stand  several  hours.  Chlorinated  lime,  too,  is  used. 
It  must  be  fresh,  as  it  soon  deteriorates  on  exposure  to  the  air.  A  1  per 
cent,  solution  is  required;  or,  to  avoid  making  exact  solutions,  a  handful 
is  put  in  the  pan  with  the  stool  and  enough  water  to  cover  and  mix  it 
with.  Bichloride  is  not  reliable  for  disinfecting  stools.  Urine  is  disin- 
fected with  1  to  20  phenol,  using  one-third  to  equal  amounts.  The  lesser 
amount  has  been  shown  to  be  effectual  after  one  and  one-half  hours' 
contact.  One  to  1,000  bichloride,  in  volumes  equal  to  1/15  to  1/40  of  the 
urine,  standing  for  an  hour  and  a  half,  is  effectual. 

Bath  water  may  be  disinfected  by  adding  Y^  pound  of  chlori- 
nated lime  to  a  tub  (200  litres)  of  water  and  allowing  it  to  stand  an  hour. 

Bed  linen  should  be  soaked  in  1  to  20  phenol  for  two  hours 
or  in  formalin,  3  ounces  to  a  gallon,  for  twelve  hours,  and  then  thor- 
oughly boiled.  Bed  pans,  urinals,  rectal  tubes,  and  rubber  sheets 
can  be  disinfected  in  phenol  1  to  20  and  allowed  to  soak  in  it. 

Knives,  forks,  spoons,  and  crockery  can  be  thoroughly  boiled. 
Sputum  is  best  burned;  vomitus  may  be  treated  with  phenol 
and  lime. 


282  TREATMENT  OF  ACUTE  INFECTIOUS  DISEASES 

Mattresses  can  be  disinfected  after  the  disease  is  over  with 
dry  heat,  and  the  room  should  be  disinfected. 

The  nurses  should  give  tub-baths,  wearing  rubber  gloves  and  a  rubber 
apron.  If  given  with  the  bare  hands,  and,  indeed,  after  handling  secre- 
tions, the  hands  should  be  carefully  washed  and  soaked  in  1  to  1,000 
bichloride. 

It  must  be  remembered  that  the  administration  of  hexamethylenamine 
(urotropin)  by  the  mouth  disinfects  an  acid  urine,  but  we  should  not 
intermit  the  precautions  just  named. 

Diet.  Everyone  who  has  treated  typhoid  fever  has  felt  that 
the  most  urgent  problem  he  has  to  meet  is  the  dietary.  He  has  con- 
sulted authority  with  the  result  that  he  has  come  away  more  bewildered 
than  instructed.  He  has  been  urged  to  maintain  a  low  diet,  lest  too 
great  a  burden  be  thrust  on  digestive  organs  and  tissues  weakened  by 
disease,  or  damage  be  done  to  the  inflamed  intestinal  wall  with  the  pro- 
duction of  hemorrhage  or  perforation;  on  the  other  hand,  he  has  been 
taught  to  give  the  patient  great  freedom  in  diet,  lest  strength  be  sacrificed 
as  the  result  of  starvation.  He  has  read  arguments  for  liquid  food,  for 
solid  food,  for  stimulating  food,  for  bland  food,  until  in  his  despair  he 
chooses  some  guide  with  whom  he  is  more  or  less  well  acquainted,  copies 
his  directions  with  slavish  exactness,  and  proceeds  to  feed  all  patients 
by  this  measure. 

We  are  dealing  here  with  a  fever  and  a  long  fever,  during  which  oxi- 
dative  changes  must  be  met,  either  at  the  expense  of  food  ingested  or  of 
the  body  itself,  and  during  which  extensive  tissue  destruction  is  going 
on  as  the  result  of  the  disease;  this  must  be  made  good  by  the  food  or 
the  deficit  will  increase  continuously  up  to  convalescence,  or  bring  about 
a  bankruptcy,  before  convalescence  can  be  attained. 

The  first  great  fact  to  be  kept  in  mind  in  all  fevers  is  that  the  body 
demands  as  much  energy  and  heat  in  terms  of  heat  units  in  fever  as  it 
does  in  ordinary  rest  in  health;  we  will  say  33  calories  per  kilo,  or  some 
2,300  calories  for  a  man  of  70  kilos,  or  154  pounds;  and  that  as  a  result 
of  the  fever  itself,  he  usually  needs  some  25  per  cent,  more,  or  about  4ft 
calories  per  kilo,  or  some  2,800  calories  for  a  154-pound  man.  Therefore, 
he  ought  to  get  2,800  calories  to  meet  this  need  from  his  food,  unless  he 
takes  it  out  of  his  own  body. 

The  second  great  fact  with  reference  to  the  body  needs  to  be  met  by 
the  food,  is  that  there  must  be  a  certain  minimum  of  protein  in  the  diet. 
Voit's  standard  was  something  over  100  grams  per  day,  but  more  recent 
work  has  shown  that  even  less  would  do,  but  that  some  70  grams  should 
be  afforded.  This  demands  intelligent  scrutiny  of  the  food,  with  the 
knowledge  of  its  composition,  in  order  that  this  minimum  should  be 


TYPHOID  FEVER  283 

observed;  or,  what  is  next  in  importance,  that  it  should  not  be  too  much 
overstepped. 

The  third  great  body  of  facts,  in  dealing  with  diet  in  fever,  are  those 
which  inform  us  of  the  loss  of  protein  to  the  body  in  fever  and  how  to 
shelter  it  by  the  food  administered.  The  wasting  after  fever,  even  a 
short  fever,  and  so  emphasized  after  a  long  one,  is  one  of  the  most  fa- 
miliar phenomena  of  disease.  The  wastage  is,  of  course,  due  to  loss  of 
both  fat  and  protein,  but  more  especially,  from  the  standpoint  of  im- 
portance, of  protein. 

The  destruction  in  fever  may  be  assigned  to  three  particular  causes: 
(1)  Starvation.  There  can  be  no  doubt  that  our  patients  are,  in  too 
many  instances,  underfed.  That  this  cause  for  protein  loss  can  in  a 
goodly  measure  be  prevented  goes  without  saying.  (2)  Fever  itself. 
Pyrexia  exerts  a  destructive  action  on  protein  of  the  tissues,  as  can  be 
determined  by  studying  the  nitrogenous  output  in  fever  induced  arti- 
ficially in  animals,  as  in  hot  baths  or  by  puncture  of  the  floor  of  the 
fourth  ventricle.  In  disease,  however,  it  is  not  always  easy  to  separate 
it  from:  (3)  toxic  destruction,  meaning  the  breakdown  induced  by  the 
toxins  of  the  infecting  organisms,  in  part  autolytic,  perchance,  but  the 
detail  of  which  is  still  obscure. 

The  influences  of  pyrexia  can,  to  a  certain  degree,  of  course,  be  influ- 
enced by  hydrotherapeutic  and  other  antipyretic  measures.  The  effect 
of  the  toxins,  until  we  have  specific  sera  or  other  specific  measures  at 
our  command,  however,  are  not  under  our  control;  and  yet,  it  is  surpris- 
ing how  near  to  a  nitrogenous  equilibrium  a  patient  can  be  brought  in 
the  face  of  this  toxemia,  if  supplied  with  the  proper  food  hi  the  proper 
manner. 

I  am  indebted  to  the  work  of  Dr.  Shaffer  and  Dr.  Coleman  for  many 
statements  of  facts  made  here,  but  they  are  not  to  be  made  responsible 
for  any  conclusions  I  may  draw. 

In  the  disease  in  question  wasting  is  marked.  A  loss  of  10  pounds  is 
slight,  but  losses  of  40,  50,  60  pounds  or  more  may  occur.  In  this  loss, 
nitrogenous  tissue  takes  a  large  share.  Cases  in  which  the  nitrogen  loss 
has  been  studied,  show  the  equivalent  of  7  pounds  of  pure  muscle  tissue 
in  twelve  days,  of  5  1/2  pounds  of  muscle  tissue  in  eight  days,  and  not 
rarely  11/2  pounds  of  muscle  tissue  in  a  day.  This  loss  may  mean  not, 
only  a  deprivation  to  the  body  of  the  functions  this  tissue  subserves, 
but  also  disturbances,  perhaps  toxic  hi  character,  induced  by  the  effort, 
to  catabolize  this  protein.  The  nitrogen  partition  offers  similarities 
to  those  seen  in  the  toxemias  of  pregnancy,  and,  to  quote  Dr.  Shaffer's 
words,  "  there  are  severe  so-called  toxic  cases  of  typhoid  fever  which 
terminate  with  acute  yellow  atrophy  of  the  liver,  a  condition  which  ap- 


284  TREATMENT  OF  ACUTE  INFECTIOUS  DISEASES 

pears  to  be  closely  associated  with  a  particular  type  of  faulty  protein 
metabolism." 

This  loss  can  be  avoided,  to  a  greater  or  less  degree,  by  the  food.  In 
considering  the  foodstuffs,  fat,  carbohydrates,  and  protein,  one  would 
naturally  turn  to  the  proteins  to  make  good  a  loss  of  proteins,  and,  in- 
deed, that  is  necessary,  but  to  no  such  degree-  as  would  be  anticipated. 
There  must  be  enough  protein  to  maet  the  daily  needs  under  ordinary 
circumstances — the  70  grams  of  which  I  spoke.  There  may  be  a  slight 
storage  of  excess,  which  does  not  obtain  in  health,  but  if  we  give  a  frank 
excess,  it  must  be  destroyed  and  eliminated  by  the  organism,  and  more 
than  that  in  the  process  of  its  catabolism,  by  virtue  of  what  is  known 
technically  as  the  "specific  dynamic  action,"  gives  rise  to  a  large  amount 
of  heat,  which  cannot  be  utilized  for  the  purposes  of  the  body,  and  extra 
burden  is  placed  to  dissipate  the  heat.  The  result  is  that  about  140 
calories  of  protein  are  required  to  secure  100  calories  available  for  the 
purposes  of  the  body. 

Fat  on  account  of  its  well-known  tendency  to  induce  digestive  dis- 
turbances and  diarrhea,  must  be  used  with  this  fact  in  mind  and  yet  it 
is  astonishing  how  much  fat  some  of  the  patients  will  take  without  dis- 
turbance of  any  kind,  and  Coleman  notes  that  this  tolerance  is  especially 
enhanced  by  the  third  and  fourth  week  as  the  temperature  declines. 

According  to  the  best-known  investigators  in  this  field,  the  strongest 
sparers  of  body  protein  are  the  carbohydrates,  and  it  is  upon  these  that 
we  place  our  reliance  to  solve  the  problem.  It  has  been  shown  that  the 
absorption  of  the  fats,  carbohydrates,  and  protein  in  typhoid  fever, 
when  severe  diarrhea  is  not  present,  is  very  nearly  that  of  normal. 

In  the  feeding  experiments  carried  out  along  this  line  of  reasoning 
by  Dr.  Coleman  among  the  typhoid  fever  cases  in  the  wards  of  Bellevue 
Hospital  the  carbohydrate  selected  was  milk  sugar,  because  it  ferments 
with  difficulty  and  is  less  sweet  to  the  taste  than  cane  sugar  and  more 
soluble  than  the  starches. 

The  experiments  showed  that  a  nitrogen  gain  could  be  attained  when 
the  protein  intake  amounted  to  65  to  95  grams,  while  at  the  same  time 
the  caloric  content  of  the  food  was  high,  4,000  to  5,500,  or  60  to  80  cal- 
ories per  kilo;  that  is,  enough  protein  was  used  to  meet  the  daily  needs 
and  the  loss  of  nitrogen  was  stayed  by  the  high  carbohydrate  content 
of  the  food.  When  the  same  amount  of  protein  was  used  with  32  calories 
per  kilo,  the  loss  was  considerable.  When  only  16  grams  of  protein  were 
used,  but  with  62  calories  per  kilo,  the  loss  was  greatest. 

The  basis  of  the  high  caloric  diet  as  used  in  the  wards  of  Bellevue 
Hospital  is  milk,  cream,  eggs,  milk  sugar,  bread,  and  butter.  A  quart 
of  milk  affords  640  calories.  A  quart  of  cream  (16  per  cent.)  about  1,600 


TYPHOID  FEVER  285 

calories;  each  egg  80  calories;  milk  sugar  about  120  calories  to  the  ounce; 
white  bread,  homemade,  about  1,225  to  the  pound — that  is  100  calories 
to  a  thick  slice  of  1J^  ounces;  butter  about  3,600  calories  to  the  pou  nd, 
or  100  calories  in  a  pat  a  trifle  under  ^  ounce.  With  such  materials 
various  combinations  may  be  made:  1%  quarts  of  milk  will  give  1,000 
calories,  a  pint  of  cream  800,  1/2  pound  of  sugar  about  1,000  more,  four 
eggs  320  more,  thus  making  3,120  calories.  If  one  wants  a  few  calories 
more,  250  to  600  can  be  gotten  in  2  to  5  ounces  of  sugar  added  to 
lemonade. 

A  glass  of  milk  that  contains  7  ounces  of  milk,  1  ounce  of  cream,  and 
1  ounce  of  milk  sugar,  offers  about  310  calories. 

Eight  such  glasses  in  twenty-four  hours  will  give  about  2,500  calories, 
as  high  as  many  care  to  go.  The  protein,  as  well  as  the  calories,  in  this 
food  must  be  remembered.  The  milk  contains  35  grams  to  the  quart, 
and  the  cream  a  trifle  less,  25  grams;  the  eggs  8  or  9  grams;  the  bread, 
about  9  per  cent.,  or  45  grams  to  the  pound  loaf.  In  the  more  liberal 
dietary  just  suggested,  about  100  grams  are  afforded;  in  the  smaller,  70. 
Two  eggs  added  to  this  would  increase  the  protein  to  85  grams. 

Dr.  i^hattuck,  of  the  Massachusetts  General  Hospital,  has  long  ad- 
vocated a  more  liberal  dietary  in  typhoid  fever,  and  can  point  to  quite 
as  good  results  as  the  advocates  of  a  restricted  or  milk  diet.  I  will  not 
cite  his  dietary  in  full,  but  will  mention  some  of  its  items,  which  show 
one  how  varied  we  can  make  our  patient's  food  and  relieve  a  monotony 
that  threatens  a  loss  of  appetite  and  gastro-intestinal  disturbances. 
These  are  milk  and  the  various  milk  products,  some  of  which  are  better 
borne  than  others,  such  as  buttermilk,  koumys,  matzoon,  whey  or  milk 
with  tea,  coffee,  or  cocoa;  or  the  milk  can  be  diluted  with  lime  water, 
Apollinaris,  or  Vichy;  soups  of  beef,  veal,  chicken,  tomato,  potato,  pea, 
bean,  or  squash,  strained  and  thickened  with  powdered  rice,  arrowroot, 
wheat-flour,  barley,  or  egg;  gruels,  ice-cream;  eggs,  soft  boiled  or  raw, 
or  eggnog;  finely  minced  lean  meat  or  scraped  beef,  soft  crackers  with 
milk  or  soups,  soft  puddings,  soft  toast  without  crusts,  blanc  mange, 
wine  jelly,  apple  sauce  and  macaroni. 

Many  of  these  articles  have  a  low  caloric  content,  and  would  not 
serve  the  purposes  of  our  new  teaching,  but  they  show  what  is  safe  and 
what  may  be  used  to  diversify  the  dietary. 

Each  patient  must  be  carefully  studied  with  reference  to  his  dietary. 
We  can  make  a  mathematical  problem  of  his  food  needs,  but  not  of  him. 
If  he  is  highly  toxic  and  stuporous,  if  he  has  gastro-intestinal  disturb- 
ances, we  cannot  expect  him  to  ingest  or  digest  the  same  quantity  and 
quality  of  food  that  he  would  if  his  disease  was  of  a  milder  type.  We  wish 
to  avoid  the  older  policy  of  frankly  starving  our  patients,  while  we  at  the 


286  TREATMENT  OF  ACUTE  INFECTIOUS  DISEASES 

same  time  do  not  desire  to  stuff  them  like  a  Christmas  goose,  willy-nilly. 
I  believe  if  the  patient  is  moderately  or  severely  ill  when  he  comes  under 
our  observation,  we  should  begin  on  milk  for  the  first  twenty-four 
hours,  some  two  quarts;  then  a  little  milk  sugar,  a  dram  to  a  glass,  and 
rapidly  more  as  he  shows  that  he  handles  it  well;  and  at  the  same  time  or 
shortly  after,  a  little  cream — a  half  ounce  to  an  ounce  to  a  glass,  watching 
this  with  especial  care;  eggs,  gruels,  or  soups,  bread  or  toast  or  crackers, 
ice  cream,  cup-custard,  or  other  milk  modifications.  If  the  milk  is  not 
well  borne,  milk  preparations,  such  as  koumys,  matzoon,  buttermilk,  or 
whey,  may  be  used. 

If  the  tongue  is  coated,  if  there  are  eructations,  or  if  diarrhea  sets  in, 
the  cream  should  be  stopped  and  the  milk  skimmed.  Of  the  meat  soups, 
one  may  say  that  they  have  little  caloric  value,  but  may  improve  the 
appetite.  The  scraped  or  minced  meats  may  be  allowed,  if  greatly 
desired,  but  they  are  not  an  economical  form  of  food  in  fever,  owing  to 
their  high  "specific  dynamic  action,"  and  should  not  be  given  in  the 
severe  toxic  cases,  as  it  is  believed,  on  fair  grounds  for  such  an  as- 
sumption, that  the  liver  in  some  of  the  cases  is  impaired  and  unable 
to  metabolize  the  protein  of  the  food  brought  to  it,  in  the  normal 
manner. 

At  any  rate,  in  such  cases  the  urea  nitrogen  decreases  while  the  "rest 
nitrogen"  increases,  and  the  giving  of  meat  aggravates  the  condition  and 
furnishes  us  in  the  convalescence  of  severe  cases  the  so-called  "febris 
carnis,"  as  Ewing  and  Wolff  believe. 

I  believe  a  patient  should  be  given  as  much  food  as  he  will  take  and 
handle  well.  If  he  will  take  4,000  calories,  he  should  have  it;  but  with 
the  earliest  signs  of  gastro-intestinal  disturbance  or  disgust  for  food,  one 
should  diminish  the  food,  and  do  so  promptly.  The  patient's  appetite  is 
a  valuable  guide,  and  within  the  range  of  food  mentioned,  his  likes  and 
dislikes  should  be  considered.  Briefly — an  estimate  should  be  made  of 
the  body's  caloric  requirements. 

Food  must  be  palatable  and  service  attractive.  Patients'  tastes 
and  food  idiosyncrasies  must  be  considered,  but  the  diet  must  not  be 
subservient  to  whims.  The  degree  of  toxicity  of  patients  modifies  the 
procedure. 

If  the  appetite  is  large  it  may  be  gratified.  If  the  appetite  is  poor, 
try  to  improve  it  by  kind  of  food  and  service,  but  do  not  force  food  to 
the  point  of  producing  disgust.  If  there  is  frank  disgust  for  the  food  cut 
it  down  for  a  time. 

The  desire  for  food  in  the  first  week  and  during  the  fastigium  is  di- 
minished, with  the  decrease  in  fever,  appetite  improves  and  may  be 
ravishing.  The  caloric  intake  should  be  built  up  during  early  days  grad  - 


TYPHOID  FEVER  287 

ually  to  theoretical  requirements,  beginning  with  1 ,000  to  2,000  calories, 
depending  on  general  condition  and  increasing  500  calories  a  day,  to 
4,000  or  5,000  calories. 

With  the  appearance  of  gastro-intestinal  symptoms  modify  the  diet. 
These  symptoms  are  anorexia,  nausea  or  vomiting,  tympanites  and 
diarrhea. 

The  disturbance  may  be  due  to  forcing  the  feeding;  cut  down  the 
quantity  and  lengthen  the  intervals.  The  nausea  and  vomiting  may  be 
due  to  too  much  sugar;  or  to  too  much  cream,  or  eggs  are  not  well  borne. 

For  a  veritable  mine  of  information  on  this  subject  in  both  its  theo- 
retical considerations  and  practical  applications,  Dr.  Coleman's  article 
in  the  American  Journal  of  the  Medical  Sciences,  Jan.,  1912,  should  be 
consulted. 

See  Summary  for  detail  of  dietary. 

Water.  Water  should  be  given  to  the  patient  ad  libitum  and 
more  than  that,  realizing  that  in  his  stuporous  condition  the  patient's 
demands  are  no  measure  of  his  needs,  water  should  be  offered  to  the 
patient  frequently,  every  hour  or  two.  For  this  purpose  the  bent  glass 
tube  should  be  used,  but  in  highly  stuporous  conditions  the  water  must 
be  administered  with  a  spoon.  A  patient  should  be  given  2  to  3  quarts 
of  fluids  a  day  and  as  much  more  as  he  will  willingly  take.  Not  only  is 
the  intake  of  water  necessary  for  his  metabolic  needs,  but  the  functions 
of  kidney  and  skin  are  sustained  by  it,  while  the  condition  of  the  mouth  is 
improved  by  it  and  constipation  much  lessened.  Other  drinks — lemon- 
ade, and  orangeade  and  imperial  drink  may  be  given  and  these  offer 
excellent  vehicles  for  sugar,  a  highly  important  foodstuff. 

Alkaline  waters  may  also  be  used. 

Hydrotherapy.  If  one  had  a  brief  to  hold  for  hydrotherapy, 
he  could  not  do  better  than  to  appeal  to  its  application  in  typhoid 
fever.  So  thoroughly  convinced  is  the  American  practitioner  of  its 
great  value  in  this  condition  that  arguments  to  maintain  this  thesis 
are  only  of  historical  value.  The  mortality  of  typhoid  fever,  vary  as 
it  may  in  different  epidemics,  hospitals,  and  localities,  has,  under  the 
old  expectant  treatment,  amounted  to  15  per  cent,  the  world  over. 
Since  the  introduction  of  the  cold-water  treatment,  where  large  num- 
bers of  cases  can  be  collected,  as  in  great  hospital  services,  the  mor- 
tality has  been  cut  in  half,  running  about  7.5  per  cent,  with  wonderful 
uniformity  in  the  hospitals  of  our  larger  cities.  Statistics  have  no 
value  unless  applied  to  large  numbers.  For  example,  in  a  certain  hospital 
100  cases  of  typhoid  were  treated  by  the  bath,  with  a  mortality  of  1  per 
cent.  One  might  have  attributed  this  success  to  some  perfection  of 
technique  not  prevailing  elsewhere,  but  when  the  same  clinician  had 


288  TREATMENT  OF  ACUTE  INFECTIOUS  DISEASES 

collected  400  cases  his  published  mortality  showed  7.8  per  cent.,  or 
that  of  the  general  experience. 

The  hydrotherapy  of  typhoid  fever,  as  universally  adopted  in  this 
country,  is  based  on  the  Brand  bath,  or  a  'modification  of  it,  and 
the  greater  the  modification,  the  less  successful  it  seems  to  be.  Two 
emphatic  statements  with  reference  to  this  bath  should  be  made :  (1)  The 
essence  of  the  bath  lies  in  the  application  of  cold  water  and  friction, 
neither  one  nor  the  other  alone,  but  both;  (2)  the  purpose  of  the  bath  is 
to  improve  the  condition  of  the  poisoned  centres  and  organs:  the  heart, 
lungs,  kidneys,  and  centres  in  the  brain  and  medulla;  incidentally,  and 
to  a  degree  beneficially,  to  reduce  temperature.  The  last  is  too  often  put 
first,  which  in  this  instance  does  not  have  biblical  justification. 

Method.  The  body  should  be  immersed  to  the  neck;  the  bath 
should  be  given  preferably  in  a  tub.  In  hospital  practice,  a  portable 
tub  on  wheels  is  used.  In  private  practice  this  is,  as  a  rule,  too  cumber- 
some, and  a  tin  bath  tub  may  be  used,  elevated  to  nearly  the  level  of  the 
bed  on  wooden  horses,  blocks,  or  other  contrivance.  Placed  alongside 
of  the  bed,  the  floor  being  protected  by  a  rubber  sheet,  oilcloth,  or  carpet, 
it  is  filled  three-quarters  full  of  water,  with  buckets,  or  a  hose  attached 
to  a  tap,  if  one  be  conveniently  near. 

The  patient's  nightshirt  is  removed,  his  genitals  covered  with  a  nap- 
kin, bound  about  the  body,  or  the  whole  body  covered  by  a  sheet,  under 
which  he  is  bathed,  which  latter  method  is  a  little  more  awkward.  He  is 
given  a  half  ounce  of  whiskey,  or  a  cup  of  hot  strong  coffee  (4  ounces) , 
the  face  bathed  with  cold  water,  a  folded  bandage  a  couple  of  inches 
wide,  bound  around  the  forehead  and  tied  below  the  occiput,  to  keep 
the  water  applied  to  the  head  from  running  into  the  eyes  and  streaming 
down  the  face,  and  he  is  then  ready  to  be  lifted  into  the  bath.  To  do 
this,  the  best  way  is  for  one  attendant  to  rest  the  patient's  head  on  one 
arm  while  he  raises  the  upper  part  of  the  body  by  lifting  under  the 
shoulders,  while  another  attendant  lifts  the  lower  extremities,  the  patient 
being  requested  to  stiffen  himself  out. 

Another  method,  which  has  advantages  if  the  patient  is  very  stupo- 
rous,  is  to  spread  a  hammock  netting  under  him  or  a  strip  of  canvas  with 
straps  attached,  and  lift  him  on  this  into  the  tub  and  by  the  same  means 
out  of  it.  The  head  should  rest  on  a  water-cushion  ring  or  air-ring. 

As  soon  as  the  patient  is  immersed  in  the  bath,  the  equally  impor- 
tant part  of  the  procedure  is  begun — the  friction,  gently  applied  (not 
kneading)  to  all  parts  of  the  body  except  the  abdomen.  The  back 
must  not  be  forgotten.  At  intervals  during  the  bath,  cold  water,  at 
50°  F.,  should  be  poured  over  the  head.  While  in  the  bath  the  bed  should 
be  prepared  for  his  reception,  by  placing  on  it  a  double  blanket,  on  the 


TYPHOID  FEVER  289 

side  he  will  occupy;  a  pillow  is  covered  with  a  towel,  the  blanket  is 
covered  with  a  linen  sheet,  and  hot-water  bottles  are  placed  at  the  foot. 

The  patient  is  then  lifted  onto  the  bed,  the  napkin  is  removed,  and 
he  is  surrounded  by  the  sheet,  the  edges  and  ends  being  tucked  about 
the  neck  and  under  the  arms.  He  may  be  allowed  to  lie  in  the  sheet 
for  five  or  ten  minutes  and  then  dried  with  soft  towels,  or  more  imme- 
diately if  the  temperature  is  low  and  he  is  shivering.  The  tub  is  best 
emptied  by  a  siphon. 

The  temperature  of  the  water  Brand  set  at  not  more  than  70°  F., 
and  not  less  than  65°  F.  The  frequency  he  advised  was  every  three 
hours,  if  the  rectal  temperature  was  above  102.5°  F. ;  the  length  of  the 
bath,  fifteen  minutes.  These  rules  laid  down  by  Brand  have  met  with 
but  slight  modifications  where  satisfactory  results  are  obtained.  Slightly 
lesser  temperature  of  water  is  used  at  times,  a  little  higher  temperature 
of  the  body  taken  as  the  indication  of  the  bath,  and  the  initial  bath 
begun  at  a  milder  temperature;  that  is,  the  tub  bath  may  be  given  at 
80°  F.,  and  in  selected  cases  as  low  as  70°  F.  the  bath  is  continued 
fifteen  minutes,  and  given  every  four  hours,  if  the  rectal  temperature  is 
103°  F. 

Sometimes  the  tub  bath  is  given  at  85°  F.  for  ten  to  fifteen  minutes,  at 
four-hour  intervals,  if  the  body  temperature  is  102.5°  F. 

It  is  fully  appreciated  by  the  advocates  of  the  Brand  system  that 
the  reaction  to  a  bath  at  65°  F.  cannot  be  anticipated  in  markedly 
toxemic  cases,  so  that  a  patient  seen  in  the  third  week  or  latter  part  of 
the  second,  who  is  very  toxic,  should  be  subjected  to  a  bath  of  higher 
temperature  (75°  F.  or  80°  F.),  and  for  a  shorter  time.  Our  hospitals 
rarely  get  patients  in  the  first  week,  and  the  higher  temperatures  adopted 
are  better  suited  to  their  class  of  cases. 

If  a  tub  bath  cannot  be  obtained,  a  substitute  for  one  can  be  con- 
structed in  the  bed  by  running  a  clothesline  around  the  bed,  at  a  suitable 
height  above  its  level,  attaching  a  rubber  sheet  to  it  by  clothes-pins,  thus 
making  a  tub  of  the  sheet.  Other  contrivances  can  be  resorted  to,  to 
approximate  a  tub  in  the  bed,  as  building  around  the  sides  and  foot  and 
head  with  rolled  blankets,  and  the  use  of  the  rubber  sheet  as  the  recep- 
tacle for  the  water.  When  the  patient  is  put  in  the  water  one  expects  a 
sudden  shock,  deep  breath,  and  gasping.  These  are  in  themselves  bene- 
ficial. The  patient  may  shiver,  the  skin  may  be  shrivelled,  and  the  nails 
cyanotic,  and  yet  not  contraindicate  the  bath ;  but  if  the  face  is  cyanotic, 
shivering  marked,  and  chattering  of  the  teeth  occur,  and  the  patient  does 
not  react  well  on  being  taken  from  the  bath,  then  the  next  bath  should  be 
at  a  higher  temperature  and  less  long.  Cyanosis  of  the  face  or  threatened 
collapse  should  lead  to  immediate  removal  of  the  patient,  warmth  to 


290  TREATMENT  OF  ACUTE  INFECTIOUS  DISEASES 

the  body  externally  and  internally,  and  stimulants — hot  coffee  or  hot 
whiskey. 

Many  untoward  symptoms  in  the  bath  are  due  to  failure  to  appreciate 
the  value  of,  and  failure  to  apply  properly  the  friction  during  the  bath. 

The  benefit  derived  from  the  bath  is  very  obvious  and  is  expressed 
by  improvement  in  the  functions  of  various  organs.  No  bejaefit  can 
be  expected  from  any  procedure  applied  to  the  moribund,  and  the 
greatest  success  in  the  treatment  of  typhoid  fever  by  this  method  is 
in  the  early  application  of  it.  Many  of  the  severe  symptoms  seen  in 
cases  coming  under  observation  or  treatment  late,  are  not  observed  at  all 
in  the  cases  bathed  the  first  week.  The  most  characteristic  effect  clini- 
cally of  typhoid  fever  is  the  toxemia  impinging  on  the  brain,  inducing 
restlessness,  sleeplessness,  delirium,  stupor,  and  subsultus  tendinum. 
The  stimulating  effect  on  these  centres,  receiving  sensations  pouring  in 
from  every  point  of  the  periphery  and  nourished  by  a  better  blood 
supply,  is  shown  by  an  amelioration  of  every  one  of  these  symptoms, 
better  sleep  and  more  quiet,  and  a  clearer  mind  more  alive  to  its  environ- 
ments. 

In  typhoid  fever  the  pulse  is  slow;  when  rapid,  ominous;  it  is  often 
dichrotic,  bespeaking  a  low  vasomotor  tone.  We  stand  in  dread  of  heart 
failure,  but  the  opinion  prevails  to-day  that  in  acute  infectious  diseases 
the  heart  rarely  fails,  but  that  the  vasomotor  apparatus  is  the  first  to 
falter. 

After  the  tub,  the  pulse  is  smaller  and  harder,  losing  its  dichrotism; 
the  pressure  increases  by  15  to  20  mm.  Hg.,  and  the  rate  falls.  All  this 
is  very  real,  and  may  be  attributed,  in  all  probability,  to  the  effect 
exerted  on  the  vasomotor  centres,  though  the  tonic  effect  on  the  vas- 
cular walls  of  the  periphery  is  undoubtedly  a  factor. 

On  the  respiratory  apparatus  a  beneficial  effect  is  exerted  by  the  fact 
that  the  contact  with  the  cold  water  causes  the  patient  to  take  deep 
breaths,  which  lessen  the  danger  of  passive  congestion  and  hypostatic 
pneumonia  that  threaten  in  severe  cases.  More  than  that,  the  respi- 
ration of  the  tissues  is  enhanced,  as  increased  oxidation  can  be  demon- 
strated by  measuring  the  oxygen  intake  and  the  COi  output. 

The  contact  of  the  cold  water  and  the  friction  improve  the  circulation 
in  the  skin  and  so  improve  its  functions.  The  improved  condition  of 
the  circulation  increases  the  elimination  of  urine  and  the  toxins  of  the 
disease.  The  temperature  is  lowered,  but  this  is  no  longer  considered 
the  object  of  the  treatment,  and  often  in  the  height  of  the  disease  the 
temperature  is  not  influenced,  but  striking  improvement  in  the  general 
condition  is  attained,  in  terms  just  given. 

After  all,  it  is  the  individual  that  is  being  treated,  and  this  means 


TYPHOID  FEVER  291 

that  a  precise  procedure  cannot  be  the  optimum  for  every  case.  Higher 
temperature  of  the  water  and  shorter  baths  are  required  for  those  who 
stand  the  shock  of  the  typical  bath  poorly,  for  those  toxic  and  advanced 
in  the  course  of  the  disease,  and  for  children. 

Contraindications  for  the  baths  comprise  hemorrhages  and  signs 
attributable  to  perforation  or  peritonitis,  all  of  which  conditions 
demand  absolute  rest  until  the  proper  procedure,  surgical  or  otherwise, 
can  be  carried  out.  Cholecystitis,  phlebitis,  pleurisy,  if  accompanied 
by  considerable  pain,  contraindicate  the  bath  for  a  like  reason.  Cyano- 
sis and  syncope  demand  cessation  of  the  bath  in  which  they  occur,  but 
if  the  case  is  a  severe  one,  the  use  of  water  may  be  continued  in  a  milder 
form  of  application.  Large  bedsores,  because  of  the  difficulty  of  properly 
treating  them,  contraindicate  the  bath.  Bronchitis,  pneumonia,  the 
milder  grades  of  kidney  involvement,  and  menstruation  and  pregnancy 
do  not  call  for  a  change  of  procedure. 

Ziemssen's  Bath.  Beside  the  full  bath  of  Brand,  there  are  cer- 
tain other  methods  of  applying  water  in  this  disease.  A  slight  modifi- 
cation of  the  Brand  bath  is  the  so-called  graduated  bath  of  Ziemssen. 
The  details  are  the  same  as  for  the  Brand  bath,  except  that  the  water 
is  warmed  to  90°  F.,  and  then,  after  the  patient  is  in  the  bath,  is  cooled 
down  to  70°  F.  by  adding  cold  water  as  the  bath  proceeds.  The  bath 
lasts  half  an  hour  with  friction.  This  is  a  suitable  procedure  for  those 
who  stand  the  bath  poorly,  or  think  they  do,  and  refuse  the  colder  bath, 
or  the  very  toxic  cases  of  the  later  stages,  or  children. 

Slush.  When,  for  any  reason,  it  is  not  feasible  to  use  the  tub 
an  approximation  to  the  methods  and  results  of  a  tub  are  attained  by 
what  is  sometimes  called  a  slush.  The  patient  is  stripped,  a  rubber 
sheet  of  ample  proportions  is  put  under  him,  the  edges  of  which  are 
elevated  by  pillows  and  blankets  folded  to  the  formation  of  a  trough. 
Water  is  poured  into  this  trough  and  the  patient  given  a  bath  with 
friction,  as  in  a  tub,  while  cold  compresses  are  kept  at  his  head.  The 
water,  of  course,  becomes  warm  rapidly  and  is  kept  cold  by  adding  bits 
of  ice.  The  temperature  cannot  be  so  accurately  regulated  as  in  the  tub. 
The  head  of  the  bed  is  elevated,  the  water  drained  off,  the  patient  rubbed 
with  a  little  alcohol,  or  alcohol  and  water,  after  drying  and  removing 
the  rubber  sheet,  and  then  dusted  with  talcum.  These  slushes  may  be 
very  effectual  when  properly  given. 

Packs  and  Sponges.  When  the  baths  are  refused,  or  for  other 
reasons  cannot  be  given,  packs  and  sponges  may  be  substituted;  but, 
while  these  afford  comfort  and  do  some  good,  they  fail  in  the  general 
stimulating  effect  that  comes  from  the  friction  of  the  body  immersed 
in  cold  water. 


292  TREATMENT  OF  ACUTE  INFECTIOUS  DISEASES 

Care  of  the  Alimentary  Tract.  In  the  routine  treatment  of 
typhoid  fever  there  are  no  organs  whose  functions  have  to  be  so  jealously 
guarded  as  those  of  the  alimentary  tract,  not  only  because  failure  of 
digestion  and  absorption  threaten  a  fatal  issue  in  so  long  a  disease,  but 
because  insufficient  elimination  and  excretion  heighten  the  toxemia, 
and  because  diarrhea  exhausts  and  hemorrhage  and  perforation  await 
upon  the  advance  of  the  local  lesions.  Constipation  is  almost  constant 
in  typhoid  fever  as  we  see  it  in  New  York.  Diarrhea,  which  one  might 
gather  from  any  of  the  text-books  as  characteristic,  is  rather  the  excep- 
tion. 

Catharsis.  If  seen  early,  a  catharsis  of  castor  oil,  1  ounce  (30  c.c), 
or  Epsom  salt,  1  ounce  (30  Gm.),  may  be  given.  If  seen  late,  a 
catharsis  should  be  avoided.  Enemas  of  tepid  water,  of  soapsuds, 
or,  in  obstinate  cases,  soapsuds  with  an  ounce  of  sweet  oil,  or  castor  oil, 
should  be  given  every  other  day.  It  is  the  lower  bowel  one  wishes  to 
empty,  not  the  upper,  and  this  can  be  done  effectually  with  the  enema. 
The  upper  bowel,  the  site  of  the  lesion,  like  any  other  inflamed  part, 
should  be  given  as  much  rest  as  is  compatible  with  its  physiological 
functioning. 

The  lower  bowel  is  physiologically  differentiated;  the  lower  part  form- 
ing the  reservoir  for  undigested  food,  and,  what  is  more  important,  the 
excreted  matter,  the  nitrogenous  content  of  which  forms  an  almost  con- 
stant portion  of  the  total  nitrogen  output;  it  is,  too,  the  site  of  active 
bacterial  action,  and  is  an  absorbing  surface.  We  wish  to  avoid  absorp- 
tion of  toxic  material  of  bacterial  action,  which  may  add  its  burden  to 
the  already  overloaded  blood.  Nothing  is  more  surprising  than  the 
large  stools  obtained  from  patients  on  a  milk  diet,  and  still  more,  the 
considerable  movements  obtained  when  patients  are  taking  little  or  no 
food.  The  patient's  plea,  to  avoid  the  enema,  that  he  has  taken  nothing, 
therefore,  can  have  nothing  to  evacuate,  must  be  met  by  explanation  of 
the  physiological  fact  and  demonstration  of  its  accuracy. 

Tympanites,  to  some  degree,  is  almost  constant,  but  when 
marked  is  usually  the  expression  of  the  severity  of  the  intoxication. 
This  paretic  condition  of  the  bowel,  which  allows  the  collection  of  large 
quantities  of  gas,  is  rife  with  danger,  as  it  increases  the  chances  of 
hemorrhage  and  perforation,  and  interferes  with  respiration  and  cardiac 
action;  pain  may  be  an  accompaniment.  The  free  use  of  water,  the 
attention  to  periodical  evacuation  of  the  bowel,  and  the  general  tonic 
effect  of  the  baths,  lessen  the  severity  of  this  complication. 

If  milk  sugar  is  being  used  freely,  this  should  be  suspected  and  cut 
down  or  eliminated  until  its  responsibility  is  determined  and  the  con- 
dition relieved. 


TYPHOID  FEVER  293 

When  in  spite  of    such    precautions,  it  does  obtain,  the  following 
measures  may  be  carried  out: 

1.  Introduce   for  a  distance  of  12  to   15  inches  into   the   bowel 
a  soft,  pliable  rubber  catheter,  taking  great  care  not  to  use  force. 
The  larger  bowel  is,  as  a  rule,  more  implicated  than  the  smaller.    This 
will  at  times  permit  the  escape  of  considerable  amounts  of  gas.    It  should 
be  left  in  ten  to  twenty  minutes,  or  even  a  half  hour,  and  may  be  repeated 
every  two  to  four  hours,  as  indicated.    Turning  the  patient  while  the 
tube  is  in  place  may  facilitate  the  escape  of  gas. 

2.  The  use   of  stupes.     Two  or  three  thicknesses   of  flannel  are 
wrung  out  of  hot  water,  as  dry  as  possible,  and  applied  every  three  or 
four  hours.    The  technique  is  as  follows:    A  flannel  roller  is  put  under 
the  patient,  the  abdominal  wall  smeared  with  vaseline,  the  stupes 
applied,  the  edges  being  turned  under  to  prevent  dripping;  oil  silk  ap- 
plied, and  the  roller  brought  up  over  the  stupes  in  the  manner  of  a  binder. 
This  should  be  changed  every  two  or  three  minutes  for  ten  or  fifteen 
minutes,  or  every  ten  or  fifteen  minutes,  for  several  hours. 

3.  Turpentine.    There   are   three  ways  of   administering   turpen- 
tine to  relieve  this  condition:    First,  in  the  stupes,  by  adding  a  dram 
of  turpentine  to  the  hot  water  into  which  the  flannels  are  to  be  dipped; 
by  sprinkling  the  stupes  with  turpentine;  or  by  very  lightly  passing  a 
bit  of  absorbent  cotton  wet  with  turpentine  over  the  abdomen  before 
applying  the  stupes.    Care  must  be  constantly  exercised  not  to  irritate 
or  burn  the  skin.    Careless  application  of  the  turpentine  will  certainly 
entail  such  trouble.    The  second  method  is  by  giving  turpentine  enemas. 
One-half  to  one  ounce  of  turpentine  is  to  be  used  in  one  pint  of  soapsuds 
enema.    The  method  is  as  follows:    Take  a  little  hot  water  and  a  piece 
of  castile  soap;   make  a  thick  soapsuds;  add   the  turpentine  slowly, 
constantly  stirring.    This  makes  an  emulsion.    Add  the  pint  of  water, 
and  the  emulsion  remains  stable.    Oil  enemas  are  made  in  the  same  way. 
The  third  method  is  by  the  mouth;  10  to  20  drops  are  used  every  four 
hours.    It  is  sometimes  dropped  on  loaf  sugar,  but  the  turpentine  makes 
the  sugar  tough  and  not  easily  soluble.    It  is  better  given  in  capsules, 
10  minims  each  (0.60  c.c.),  or  in  emulsion,  to  which  a  little  oil  of  cin- 
namon may  be  added  as  a  flavor,  while  at  the  same  time  it  adds  to  the 
effect  of  the  turpentine.    Thus: 


Olei  Terebinthinae  Rectificati  ............  10 

Olei  Cinnamomi,  q.  s.  or  .................  0.1          gtts.  ii    or  q.  s. 

Acaciae  .................................  q.  s.          q.  s. 

Aq.  Destillatae  q.  s.  ad  ..................  60.0          gii 

M.  et  fiat  emulsum 

Sig.  —  One  or  two  teaspoonfuls. 


294  TREATMENT  OF  ACUTE  INFECTIOUS  DISEASES 

Milk  and  Molasses  Enema.  An  expedient  often  used  for  tym- 
panites after  operation  is  the  milk  and  molasses  enema.  This  is  made 
by  adding  8  ounces  of  milk  to  8  ounces  of  molasses  which  has  been  pre- 
viously warmed,  both  to  make  its  consistency  thinner  and  to  obtain 
body  temperature.  This  is  slowly  introduced  through  a  rectal  tube 
inserted  not  more  than  6  or  8  inches. 

Peppermint  Enema.  A  fairly  effectual  enema  in  tympanites 
is  one  in  which  1  or  2  teaspoonfuls  of  spirits  of  peppermint  are  added 
to  the  quart  of  warm  saline  or  plain  water.  (Dr.  T.  F.  Goodwin.) 

Pituatrin.  Pituatrin,  which  stimulates  the  smooth  muscle  of 
the  intestinal  wall,  may  be  used  hypodermically  in  obstinate  cases. 
This  substance  may  be  obtained  in  ampoules  ready  for  hypodermic  use. 
The  amount  given  is  usually  1  c.c. 

Sometimes  a  large  flat  ice  bag  or  the  ice  coil,  brings  relief,  and  if  all 
these  measures  fail,  a  hypodermic  injection  of  physostigmine  salicylate 
or  sulphate  (1/50  grain)  (0.001  Gm.)  may  be  tried.  The  diet  should  be 
materially  decreased,  milk  stopped,  and  albumin  water  administered, 
and  water  given  freely,  if  the  condition  is  severe. 

Diarrhea,  fortunately,  is  not  a  common  complication  in  ty- 
phoid as  we  see  it  here.  Two  or  three  loose  movements  a  day  do  not 
call  for  interference,  except  in  the  matter  of  regulation  of  food. 
The  food  and  neglect  of  the  bowel  may  be  the  inciting  causes.  If  the 
patient  is  on  a  milk  diet,  the  fat  is  more  likely  to  be  responsible  for  the 
diarrhea  than  any  other  constituent  of  the  food,  and  should  be  removed. 
Scalding  the  milk  may  help.  If  the  diarrhea  is  severe,  the  food  should 
be  cut  down.  Of  the  astringents,  bismuth  subnitrate  is  the  best,  and 
should  be  given  in  sufficient  doses  (30  grains)  (2  Gm.)  every  two  or  three 
hours.  This  must  not  be  kept  up  too  long,  or  if  administered  over  a  long 
perio/d,  it  must  be  remembered  that  the  bismuth  may  be  retained  in 
the  bowel  in  such  quantities  as  to  produce  irritation  by  sheer  weight, 
while  the  diarrhea  still  continues;  hence,  the  necessity  for  irrigations. 

Prolonged  saline  irrigations,  by  improving  diuresis,  lessening 
toxemia,  and  keeping  the  bowel  clear,  may  be  of  distinct  advantage. 
It  is  tempting  to  use  opium,  but  it  cannot  be  too  emphatically 
insisted  upon  that  by  so  doing,  pain,  the  earliest  and  most  important 
symptom  of  perforation,  may  be  lacking — to  the  patient's  undoing. 
It  should  not  be  used  unless  exhaustion  from  diarrhea  and  increasing 
danger  of  hemorrhage  and  perforation  from  peristaltic  unrest  seem  to 
demand  it.  Then  one  may  give  a  few  large  doses,  rather  than  long- 
continued  small  ones;  for  example,  a  pill  of  opium  (1/2  grain)  (0.030 
Gm.)  every  two  hours  for  three  of  four  doses,  or  some  such  marked 
astringent  mixture  as  one  of  our  well-known  clinicians  has  advised : 


TYPHOID  FEVER  295 


Pulv.  Opii  ..............................  0.25  (gr.  iii%) 

Pulv.  Camphorse  ........................  1  .  00  (gr.  xv) 

Plumbi  Acetatis  .........................  3.00  (gr.  xlv) 

Bismuth.  Subnitrat  ......................  30.00  (g  j) 

M.  et  div.  in  chart  no.  xv. 
Sig.  —  One  every  four  hours. 

Gastric  distress  and  vomiting  are  not  common.  If  vomiting 
does  occur,  both  fats  and  milk  sugar  should  be  suspected  and  these 
eliminated  from  the  diet  until  the  symptoms  subside  and  then  re- 
introduce  cautiously.  Cracked  ice,  in  small  pieces,  sucked,  may 
be  of  avail.  Then  try  a  mild  mustard  paste  to  the  epigastrium, 
one  part  in  four  of  flour.  If  these  do  not  succeed,  try  a  bland  powder 
of  cerium  oxalate  (3  grains)  (0.20  Gm.),  sodium  bicarbonate  (5 
grains)  (0.30  Gm.),  and  bismuth  subnitrate  (10  grains)  (0.60  Gm.) 
every  two  hours.  If  very  severe,  cocaine  hydrochloride  (1/5  grain) 
(0.01  Gm.),  in  tablet  form,  or  one  teaspoonful  of  0.1  per  cent,  solution 
every  two  or  three  hours.  Finally  stomach  washing  may  succeed 
when  other  measures  have  failed. 

Hemorrhage.  Few  things  are  more  trying  than  meeting  the 
danger  arising  from  hemorrhage  and  perforation.  Few  occurrences 
demand  more  judgment  and  common  sense  than  treating  the  hemorrhage 
of  typhoid.  To  judge  by  the  advice  given  by  some  authors,  the  appear- 
ance of  hemorrhage  is  to  be  treated  like  an  invading  foe,  to  be  met 
with  every  weapon  at  our  command,  from  stiletto  to  bludgeon;  while 
more  timid  counsellors  urge  letting  it  severely  alone,  lest  by  interference 
we  come  off  worse  than  before.  It  is  interesting  to  note  that  many 
competent  clinicians  both  of  the  past  and  present  have  conceived  the 
idea  that  in  non-fatal  cases  of  hemorrhage  actual  benefit  accrued  to 
the  bleeding,  in  terms  of  improvement  in  pulse,  temperature  and  general 
condition,  and  Rudolph  finds  authority  for  the  statements  that  bleeding 
brings  about  an  increase  in  the  urine,  increases  the  intake  of  oxygen, 
hastens  coagulation  time  and  enhances  the  production  of  anti-bodies 
in  the  blood.  These  facts  have  suggested  venesection  in  severe  cases 
of  typhoid  and  the  measure  has  actually  been  carried  out,  but  —  with 
what  benefit  I  am  not  competent  to  state.  In  the  first  place,  in  the 
early  stages,  a  little  blood  may  appear  in  the  stools,  resulting  from  an 
oozing  of  the  hyperemic  patches,  and  such  small  amounts  at  such  a 
period  need  no  treatment.  In  the  latter  part  of  the  second  week,  and 
during  the  third,  we  are  anticipating  the  hemorrhages  of  real  significance 
from  the  ulcers  and  know  that  they  do  occur  in  about  7  per  cent,  of  the 
cases.  If  the  hemorrhage  is  mild,  that  is,  small  in  amount,  or  well  borne 


296  TREATMENT  OF  ACUTE  INFECTIOUS  DISEASES 

by  the  patient,  we  may  have  no  premonition  of  it  until  the  stool  shows 
the  red  blood  of  the  recent  bleeding,  or  the  tarry  stool  of  one  occurring 
some  hours  before. 

In  these  "cases,  the  present  bleeding  is  of  less  importance  than  that 
which  may  occur  later,  so  that  our  treatment  is  largely  prophylactic. 
We  cut  down  the  food,  we  enjoin  absolute  muscular  rest  on  the 
part  of  the  patient,  and  turn  him  gently  when  required. 

We  may  apply  a  light  flat  ice  bag  or  coil  to  the  abdomen. 
We  may  give  calcium  lactate  in  doses  of  10  grains  (0.60  Gm.) 
three  times  a  day,  and  in  the  light  of  our  recent  knowledge  of  the 
effect  of  horse  serum  on  coagulation,  we  may  give  a  dose  of  10  to 
20  c.c.  of  it;  or,  failing  that,  diphtheria  antitoxin  in  similar  amounts. 
To  get  the  best  results  from  the  serum,  it  should  be  as  fresh  as  possible. 
The  old  serum  loses  much  of  its  potency  in  this  respect.  If  fresh  horse 
serum  is  not  available,  fresh  rabbit's  serum  may  be  used.  Human 
serum  is  the  best  of  all  (Welsh). 

Antitoxin,  because  it  is  likely  to  be  old,  is  less  valuable,  and  when 
a  concentrated  antitoxin,  made  from  the  globulins,  of  no  use  at  all. 
The  usual  test  for  sensitization  for  horse  serum  should  be  made  and 
the  history  of  the  past  serum  administration  or  asthma  investigated. 
If  sensitization  is  determined,  desensitization  must  be  effected.  (See 
Pneumonia,  Chap.  IX.) 

An  initial  dose  of  serum  after  a  matter  of  ten  days  might  possibly  es- 
tablish an  anaphylaxis,  and  this  precaution  is  doubly  necessary,  when  a 
second  dose  is  given  after  such  an  interval.  Immunity  against  anaphy- 
laxis may  be  established  by  giving  doses  of  serum — full  doses — every 
day,  or  second  day. 

More  recently  thromboplastin,  which  is  usually  prepared  from  brain 
tissue  (Kephalin),  and  is  a  coagulant  when  locally  applied  to  a  bleeding 
surface,  has  come  into  use.  It  is  furnished  commonly  in  vials  contain- 
ing 20  c.c.  This  should  be  poured  into  eight  ounces  of  water  and  given 
by  mouth  several  times  a  day. 

If,  however,  the  hemorrhage  is  severe,  as  shown  by  the  large 
quantity  of  blood  passed  by  the  bowel,  and  even  more  if  general  symp- 
toms of  hemorrhage  prevail,  with  or  without  the  passage  of  blood — that 
is,  sudden  fall  of  temperature,  pallor,  cold  sweat,  cold  extremities,  rapid 
thready  pulse,  restlessness,  and  air-hunger,  more  decided  measures  must 
be  taken.  There  is  one  drug  that  is  of  greater  value  than  any  other, 
namely,  morphine.  The  sulphate  is  to  be  given  in  doses  of  J^  grain 
(0.015  Gm.)  under  the  skin.  Morphine  is  not  a  styptic,  nor  has  it  any 
effect  on  the  calibre  of  the  vessels  or  coagulation  time,  but  what  it  does 
do  is  to  afford  the  maximum  amount  of  rest,  both  to  the  bleeding  bowel 


TYPHOID  FEVER  297 

and  to  the  anxious  brain,  and  to  the  restless  and  uneasy  body,  whose 
useless  movements  keep  up  the  blood  pressure.  This  gives  the  bleeding 
vessel  a  chance  to  do  what  it  is  trying  to  do — form  a  clot.  It  is  pointed 
out  that  perforation  occurs  in  these  hemorrhages — one-fifth  of  the 
perforations;  and  that  the  use  of  opium  blinds  the  symptoms,  and  no 
doubt  it  does,  but,  while  anticipating  such  a  complication,  we  cannot  sit 
by  and  see  our  patient  die  from  the  hemorrhage. 

There  are  many  cases  that  come  between  these  two  extremes,  and 
success  in  those  cases  is  the  fruit  of  experience  and  judgment.  One 
can  only  say,  when  a  patient  is  to  be  under  constant  observation  for 
some  hours  to  come,  as  he  ought,  hold  off  the  opium  as  long  as  possi- 
ble. If  circumstances  will  not  permit  remaining  by  the  patient,  one 
should  not  spare  the  opium. 

The  bowels  should  not  be  moved  for  some  three  days  after  a  hemor- 
rhage, and  then  with  caution.  One  should  get  back  on  the  diet  slowly  and 
combat  meteorism. 

When  the  hemorrhage  causes  exsanguination,  it  must  be  treated 
likg  any  other  hemorrhage — elevation  of  the  foot  of  the  bed,  heat 
to  the  extremities,  saline  infusions  of  0.9  per  cent,  sodium  chlo- 
ride solutions,  or  better  yet,  Ringer's  solutions  or  transfusion. 

The  newer  methods  of  transfusion  as  described  by  Lindeman  (see 
American  Jour.  Diseases  of  Children,  Vol.  6,  No.  1,  July,  1913)  and  others 
have  so  simplified  transfusion  and  so  robbed  it  of  the  dramatic  that  the 
process  should  be  used  whenever  hemorrhage  is  repeatedly  persistent  or 
dangerously  severe. 

The  essence  of  the  procedure  is  a  rapid  transferal  by  syringe  from 
the  vein  of  the  donor  to  the  vein  of  the  patient,  or  blood  is  withdrawn  into 
an  Erlenmeyer  flask  or  similar  receptable  in  which  there  is  a  little  po- 
tassium or  sodium  citrate.  It  may  later  be  transferred  to  the  vein  of  the 
patient.  (For  technique,  see  Scarlet  Fever,  Chap.  XVII.) 

Tests  of  the  blood  to  determine  its  congeniality  to  the  recipient  must 
be  made  first,  lest  hemolysis  ensue.  The  method  is  so  simple  that  the 
transfusion  can  be  repeated  as  often  as  needed.  Moreover,  there  are 
reasons  for  believing  that  in  a  healthy  individual  a  certain  amount  of 
anti-bodies  are  present  and  certainly  complement,  which  may  be  dimin- 
ished in  the  patient's  blood  and  its  replacement  thus  have  an  additional 
beneficial  effect  on  the  patient. 

Perforation.  Even  more  dangerous  than  hemorrhage  is  per- 
foration. It  occurs  in  2  to  3  per  cent,  of  the  cases  and  causes  some  12 
per  cent,  of  deaths  in  typhoid  fever.  It  seems  to  occur  as  frequently  in 
cases  treated  with  the  bath,  but  because  of  the  lower  mortality  of  the 
disease  so  treated,  the  percentage  of  death  from  perforation  rises.  If 


298  TREATMENT  OF  ACUTE  INFECTIOUS  DISEASES 

one  in  eight  or  more  of  the  deaths  in  typhoid  fever  are  due  to  perforation, 
it  becomes  a  moral  obligation  to  know  the  signs  well.  One  will  recall  the 
sudden  onset,  with  acute  abdominal  pain,  like  a  bolt  out  of  the  blue;  its 
paroxysmal  character,  the  rapid  rise  in  the1  leukocytosis,  the  two  most 
important  early  symptoms,  I  think;  then  the  change  in  respiration,  rapid 
pulse,  distressed  expression,  local  muscle  spasm,  rigidity,  tympanites, 
with,  perhaps,  obliteration  of  the  liver  dulness. 

Every  Attack  of  Abdominal  Pain  should  mean  perforation  until 
continuous  observation  convinces  otherwise,  for  thus  its  occurrence 
will  not  be  overlooked.  When  it  occurs,  the  surgeon  should  be  sum- 
moned, an  operation  performed,  and  the  perforation  closed.  If  satisfied 
that  pain  has  no  such  significance,  one  should  consider  the  possibility 
of  acute  cholecystitis.  Carter,  studying  1,815  cases  of  typhoid 
fever,  found  that  in  one  in  75  abdominal  pain  had  this  explanation. 
It  required  the  same  consideration  as  under  other  circumstances  and 
may  or  may  not  need  surgical  intervention.  It  must  not  be  for- 
gotten that  perforation  can  occur  in  these  cases.  In  three  of  Carter's 
cases  the  pain  was  due  to  appendicitis.  If  the  condition  is  not  one 
requiring  surgical  intervention  then  the  ice  bag  or  stupes,  or  a  light 
application  of  the  cautery  or  small  doses  of  bromides  or  codeine 
may  be  used ;  or,  if  more  severe,  small  doses  of  morphine. 

The  cerebral  disturbances  are  characteristic  of  this  disease.  In 
the  early  stages  there  may  be  much  headache.  This  is  best  treated 
by  the  ice  cap.  Sleeplessness  is  another  common  occurrence,  and, 
as  has  been  explained,  in  considering  rest,  a  symptom  to  be  combated. 

Hydrotherapy  properly  applied  mitigates  this  to  a  great  degree. 
Small  doses  of  bromides  may  be  used,  or  trional  in  15  to  20  gram 
doses,  or  chloralamid  in  20  to  30  grain  doses;  but  if  it  is  marked  and 
prolonged,  morphine  is  the  best  drug  to  use.  Delirium  and  stupor 
are  best  met  by  the  baths.  In  all  decided  cerebral  symptoms 
help  may  be  obtained  from  the  tepid  bath,  with  cold  water  poured 
over  the  head;  from  the  ice-bag,  from  morphine,  and,  finally,  when 
the  delirium  is  great  or  the  stupor  deep,  from  lumbar  puncture,  an 
easy  and  innocent  procedure.  Draw  off  20  c.c.  at  least,  and  more  will  do 
no  harm,  though  headache  may  be  aggravated  by  draining  the  cord. 
No  delirious  patient  should  be  left  alone  for  a  moment.  Restraint 
by  sheets  or  other  devices  are  sometimes  needed. 

Circulation.  When  the  characteristically  slow  pulse  of  typhoid 
fever  becomes  rapid,  going  above  100  to  110  to  120,  our  concern 
is  elicited.  If  the  circulation  is  weakening,  we  shall  get  a  poorer  quality 
of  first  sound  of  the  heart,  perhaps  evidences  of  dilatation  and  mitral 
insufficiency,  poorer  quality  of  pulse,  and  a  fall  in  blood  pressure.  A 


TYPHOID  FEVER  299 

sufficiency  of  diet,  fresh  air  and  hydrotherapy  do  much  to  prevent 
this  disaster.  If,  however,  the  condition  supervenes,  stimulants  must 
be  given. 

As  in  other  infectious  diseases  the  vasomotor  apparatus  is  in  the 
great  majority  of  cases  at  fault  rather  than  the  myocardium  and  for 
this  reason  vasomotor  stimulants  would  seem  logically  to  be  indicated. 
In  cold  water  as  applied  in  the  Brand  bath  we  have  such  a  stim- 
ulus and  in  cold,  dry,  open  air  another,  but  all  our  drugs,  classed 
as  vasomotor  stimulants  are  weak  assistants,  their  effects,  as  a  rule,  not 
marked  and  their  action  short  lived.  Personally,  I  am  much  more 
impressed  with  the  digitalis  series  even  when  the  myocardium  is  not 
involved  and  much  more  when  it  is,  and  I  prefer  to  give  them  in  large 
quantities  when  the  circulation  falters.  I  give  the  infusion  gss.  (15  c.c.) 
three  times  a  day  or  the  tincture  m.  xxx  (2  c.c.)  three  times  a  day  for 
three  or  four  days,  or  if  the  patient  is  under  close  observation  longer, 
until  either  improvement  in  the  symptoms  occur,  better  quality  of  heart 
sounds,  better  pulse,  improved  blood  pressure  or  evidences  of  accumula- 
tion in  slower  pulse  or  irregularity  of  pulse  or  vomiting  or  diarrhea  ensue. 

In  urgent  circulatory  distress  I  begin  with  1/2  to  3/4  milligram 
(gr.  1/120  to  gr.  1/90)  of  strophanthin  into  a  vein  or  muscle  and 
begin  the  digitalis  at  once. 

If  one  hesitates  about  these  doses  m.  x  (0.66  c.c.)  of  the  tincture 
or  3i-ii  (4-8  c.c.)  of  the  infusion  may  be  used  three  times  a  day,  day  in 
and  day  out,  but  pressing  demands  are  not  met  by  these  small  doses. 

For  those  who  take  issue  with  my  use  of  digitalis  in  these  cases  or  if 
satisfactory  results  do  not  follow  such  usage,  I  recommend  as  vaso- 
motor stimulants  a  soluble  salt  of  caffeine,  either  the  double  salt 
of  caffeine  and  sodium  salicylate  or  benzoate  in  doses  of  gr.  v  (0.35  Gm.) 
into  the  muscle  every  four,  three  or  two  hours  or  camphor  in  solution 
in  oil  (sesame  or  olive)  10  per  cent,  or  20  per  cent,  in  doses  of  gr.  v  (0.66 
Gm.)  into  the  muscle  at  four,  three,  or  two  hour  intervals;  or  the  caffeine 
and  camphor  may  be  alternated  at  two  hour  intervals. 

I  have  less  faith  in  strychnine  but  it  is  recommended  in  doses  of  the 
sulphate  of  gr.  1/40-1/30  (1  1/3-2  mg.)  every  three  or  four  hours. 

In  threatened  collapse  adrenalin  epinephrin  1:1000  may  be  used 
in  doses  of  m.  xv  (1  c.c.)  into  a  muscle  or  m.  iii-iv  (0.20  c.c.)  into  a  vein 
and  followed  up  by  caffeine,  camphor  and  strophanthin. 

Alcohol  requires  a  special  discussion.  Briefly,  I  do  not  consider  it  a 
stimulant  in  the  true  sense  of  the  word.  Viewed  from  a  chemical,  phar- 
macological, or  therapeutic  standpoint,  I  think  the  weight  of  evidence 
is  against  its  stimulating  properties.  It  is  hard  to  conceive  that  this 
member  of  the  marsh-gas  series,  all  of  whose  other  members — alkanes, 


300  TREATMENT  OF  ACUTE  INFECTIOUS  DISEASES 

alcohols,  aldehydes,  ketones — are  depressant,  should  furnish  this  one 
exception,  ethyl  alcohol;  or  two,  ethyl  alcohol  and  ethyl  ether,  which  are 
stimulating.  The  results  of  animal  experimentation  are  decided  for  the 
depressant  effect  of  alcohol,  while  I  am  convinced  that  the  trend  of 
therapeutic  opinion  is  increasingly  in  the  same  direction. 

That  the  stimulating  effect  of  alcohol  on  the  mucous  'membrane 
of  the  stomach  may  reflexly  stimulate  the  circulation  is  left  sub  judice; 
that  alcohol  has  a  food  value  is  scarcely  denied,  and,  no"  doubt,  has  con- 
tributed to  the  patient's  strength  when  the  food  is  insufficient;  but 
neither  of  these  effects  are  justification  for  the  use  of  alcohol  as  it  has 
been  administered  in  typhoid  fever.  In  the  so-called  typhoid  state, 
characterized  by  cerebral  excitation,  sleeplessness,  rapid  pulse,  dry  skin, 
coated  tongue,  and  subsultus  tendinum,  the  picture,  to  my  mind,  is  one 
of  hyperexcitation  of  the  nervous  centres  by  the  toxins  of  the  disease.  I 
believe  that  the  improvement  seen  in  this  condition  by  the  judicious  use 
of  alcohol  is  due  to  the  sedative  effect  of  the  drug  on  these  centres  and 
not  to  stimulation.  This  conception  confines  the  use  of  alcohol  to  this 
stage  or  state  of  the  infection  and  decries  its  use  where  any  of  the  func- 
tions are  failing  from  exhaustion.  Personally,  I  would  rather  not  use  it 
at  all  in  typhoid  fever. 

The  urinary  tract  is  not  to  be  neglected.  In  the  early  days  of 
the  disease  especially,  the  patient's  bladder  may  be  overdistended.  Close 
observation  should  be  directed  to  this  organ,  and  with  the  first  evidences 
of  retention,  efforts  should  be  made,  by  hot  applications  over  the 
hypogastrium  or  by  hot  enemas,  to  provoke  urination.  If  such  measures 
fail,  catheterization  must  be  done,  but  should  be  done  by  the  physician, 
to  avoid  by  his  care  the  infection  that  so  frequently  follows  this  proce- 
dure. Overdistention  means  stagnation,  weakening  of  motility,  and 
lowered  resistance  to  infection  by  pathogenic  organisms  and  invites  a 
bacilluria.  Bacilluria  is  a  very  real  menace,  more  to  the  com- 
munity than  to  the  patient  himself,  as  true  cystitis  or  pyelitis  of  tj^phoid 
origin  is  rare.  It  occurs  in  nearly  25  per  cent,  of  the  cases,  often  in  such 
numbers  as  to  render  the  urine  turbid.  It  is  most  common  as  the  temper- 
ature begins  to  approach  the  normal  and  runs  into  convalescence.  It 
probably  arises  by  infection  through  the  kidney,  the  bacilli  finding  a  good 
culture  medium  in  the  urine,  especially  when  the  urine  is  of  a  low  acidity 
and  there  is  any  stagnation,  such  as  might  result  from  neglect  of  over- 
distention. 

The  bacilli  tend  to  disappear  spontaneously,  probably  at  such  a  time 
as  the  urine  becomes  a  less  favorable  medium  and  the  improved  tone  of 
the  bladder  facilitates  mechanical  removal.  However,  the  condition 
may  remain  for  weeks,  months  and,  in  a  few  cases,  for  years.  It  has  been 


TYPHOID  FEVER  301 

shown  that  a  high  degree  of  acidity,  and  especially  an  increasing  content 
of  organic  acid,  inhibit  their  growth.  The  effort  should  be  made  to  elimi- 
nate them,  as  a  prophylactic  measure,  for  absence  of  local  symptoms 
make  the  convalescent  an  innocent  menace  to  the  community.  Hex- 
amethylenamine  (Urotropin)  has  been  shown  to  have  an  astonish- 
ing effect  on  their  growth,  sometimes  clearing  up  a  turbid  urine  in  a  day 
or  two.  It  may  be  given  in  doses  of  5  to  15  grains  for  two  or  three  days, 
a  week,  or  continuously,  beginning  late  in  the  disease  and  continuing 
into  convalescence. 

A  good  rule  would  be,  beginning  when  the  temperature  approaches 
normal  and  continuing  for  a  month  after,  to  give  5  to  10  grains  of  uro- 
tropin  (hexamethylenamine)  three  times  a  day  for  three  consecutive  days 
each  week.  One  must  not  forget  that  some  patients  show  a  marked  intol- 
erance to  this  drug  in  terms  of  hematuria,  marked  frequency  of  urination 
and  pain.  It  must  then,  of  course,  be  stopped.  When  this  does  not 
clear  up  the  bacilli,  or  a  true  cystitis  prevails,  bladder  irrigations  of 
silver  nitrate,  1  to  5,000  daily,  or  a  saturated  solution  of  boric  acid, 
should  be  instituted. 

Vaccines.  It  is  still  difficult  to  estimate  the  value  of  vaccine 
therapy  in  the  treatment  of  an  attack  of  typhoid  fever.  That  most 
extraordinary  results,  one  might  say  dramatic,  do  occur  in  some  cases,  I 
am  myself  a  witness  to;  but  the  results  are  not  constant  and  the  reac- 
tions severe,  and  at  times  alarming;  though  I  have  not  witnessed  in  my 
own  experience  any  unhappy  outcome  as  a  result.  Gay  has  been  an 
advocate  of  this  mode  of  treatment. 

It  must  be  understood  that  the  vaccines  in  this  instance  should  be 
used  intravenously  as  the  subcutaneous  method  has  not  been  found 
equally  effectual. 

Gay  used  numerous  strains  (polyvalent)  of  B.  typhosus  which  were 
sensitized,  that  is,  treated  with  immune  serum,  washed,  killed  and 
precipitated  by  absolute  alcohol,  dried  to  constant  weight  and  ground 
and  endotoxins  extracted  with  carbolated  saline  and  the  sediment  used. 
He  conceived  vaccine  thus  prepared  to  be  less  toxic  and  to  give  less  severe 
reactions  than  the  whole  bodies  of  the  organisms. 

Others  have  used  the  whole  bodies  of  the  organisms.  My  experience 
has  been  entirely  with  these  latter.  The  reaction  is  the  same  in  kind, 
however  much  it  may  differ  in  degree. 

The  reaction  consists  of  a  chill  coming  on  a  half  hour  to  one 
hour  after  the  injection,  lasting  a  varying  length  of  time  up  to  a  quarter 
of  an  hour  and  accompanied  by  a  rise  of  temperature  of  one  to  three 
degrees  and  sometimes  to  105°  F.,  106°  F.  or  even  higher,  which  in  the 
more  exaggerated  cases  would  indicate  too  large  a  dose;  the  fever  is  at  its 


302  TREATMENT  OF  ACUTE  INFECTIOUS  DISEASES 

height  in  about  three  hours.  The  pulse  accelerates,  there  may  be  a  little 
cyanosis  and  respiratory  distress  and  the  blood  picture  shows  a  leuko- 
penia  to  even  2,000  to  3,000  at  the  height  of  the  fever.  In  about  12  hours 
the  temperature  has  fallen  to  subnormal,  accohipanied  by  sweating,  and 
a  general  amelioration  of  symptoms,  such  as  headache  and  delirium,  and 
the  patient  may  feel  perfectly  well  for  the  time.  The  leukopenia  is 
followed  by  a  leucocytosis  to  as  high  as  40,000  and  a  relative  polymor- 
phonucleosis. 

The  beginning  dose  is  25-50  million,  the  repetition  depending  on 
the  results  obtained.  If  there  is  no  reaction,  it  may  be  repeated  in  two 
days.  If  there  is  a  severe  reaction,  the  dose  is  not  increased  at  the  next 
administration.  Otherwise  the  second  dose  may  be  increased  50  per 
cent,  to  100  per  cent. 

Results.  In  Gay's  series  of  about  100  treated  with  his  sensi- 
tized vaccines  just  about  one  third  were  aborted,  one-third  benefited 
and  one-third  unaffected.  The  aborted  cases  averaged  a  duration  of 
7  days,  those  that  were  benefited  15.8  days  and  those  not  benefited 
33.1  days. 

The  mortality  in  the  series  was  6.6  per  cent.,  the  complications  were 
few,  4  per  cent,  had  hemorrhages  and  2  per  cent.,  perforations.  Relapses 
occurred  in  10  per  cent. 

Drugs  aimed  at  the  disease  itself,  intestinal  antiseptics,  etc.,  have 
been  left  out  of  consideration,  because  it  is  believed  that,  on  the  one 
hand,  no  good  results  are  to  be  obtained,  while,  on  the  other,  harm 
may  be  done  by  the  drugs  themselves  and  by  the  neglect  of  the  more 
useful  measures  advised,  entailed  by  reliance  on  the  drugs. 

Complications.  Bulky  monographs  have  been  devoted  to  the 
complications  of  this  disease  in  both  medical  and  surgical  fields.  In 
general  these  complications  are  to  be  treated  as  they  would  be  if  primary 
or  under  other  circumstances. 

I  will  mention  among  the  more  common, 

Phlebitis.  To  be  treated  by  rest  (fixation  of  the  limb)  and  ap- 
plication of  thick  layers  of  non-absorbent  cotton  (a  dry  poultice)  or 
wet  dressings  such  as  aluminum  acetate  or  poultices  frequently  applied. 

Conner  believes  thrombo-phlebitis  to  be  more  common  than  ordinarily 
accepted,  in  10  per  cent,  to  15  per  cent,  of  all  cases  and  not  always 
recognized.  Obscure  recurring  chills,  rises  of  temperature  in  convales- 
cence, prolonged  and  irregular  types  of  fever  he  believes  to  be  due  to 
such  unrecognized  phlebitis. 

Tender  toes  is  another  of  its  manifestations  and,  more  important, 
the  pleural  and  pulmonary  complications  occurring  late  in  the  course. 

Meningismus  is  not  uncommon  in  typhoid  fever  as  is  the  case 


TYPHOID  FEVER  303 

in  other  severe  infections;  for  example,  pneumonia;  but  though  very 
rare,  a  true  meningitis  due  to  bacillus  typhosus  may  occur  as  well.  The 
diagnosis  is  established  by  the  spinal  fluid  findings.  The  treatment  of 
both  conditions  is  symptomatic ;  probably  repeated  tappings  afford  some 
amelioration  of  symptoms.  For  further  treatment  of  symptoms  see 
Cerebro-Spinal  Meningitis,  Chap.  XXV. 

TREATMENT  OF  CONVALESCENCE 

After  the  temperature  has  been  normal  for  a  week  or  ten  days,  the 
patient  may  be  propped  up  in  bed,  and  in  three  or  four  days  more  be 
allowed  to  sit  up  in  the  chair,  a  little  longer  each  day,  and  if  all  goes  well, 
in  a  week  he  may  be  allowed  to  try  his  feet. 

A  slight  rise  in  the  temperature,  day  after  day,  is  one  of  the  most 
nagging  features  of  a  convalescence.  This  may  be  due  to  absorption 
from  a  neglected  bowel,  or  it  may  be  due  to  insufficient  food,  and  eminent 
clinicians  long  ago  pointed  out  that  these  patients'  temperatures  re- 
turned to  normal  when  solid  food  was  given  them.  The  older  clinician 
will  remember  the  extreme  caution  with  which  each  article  of  food  was 
given  the  patient  in  convalescence  after  a  milk  or  starvation  diet  and 
the  constant  retreats  and  modifications  with  every  little  rise  of 
temperature. 

With  the  patient  on  a  sufficient  diet  during  the  fever  we  have  no  such 
problem  to  deal  with.  The  patient  passes  into  convalescence  on  a  liberal 
diet,  which  is  maintained  to  make  up  losses  sustained  by  his  toxemia. 
Others  mend  rapidly  when  kept  in  the  air  and  light. 

Every  case  must  be  approached  on  its  merits,  and  if  the  pulse  shows  by 
its  rate  and  poor  quality  that  the  demands  on  it  are  too  great,  the  rest 
must  be  prolonged  and  the  getting  up  be  more  gradual.  To  get  the 
patient  out  in  the  sun  and  air  is  certain  to  facilitate  the  progress  of  his 
convalescence.  During  this  time  his  bowels  must  be  attended  to  with 
the  same  care  as  during  his  illness  in  bed,  at  first  aiding  with  enemas,  and 
later  with  a  mild  cathartic  like  cascara.  If  there  is  a  great  deal  of  anemia, 
Blaud's  pills  may  be  given,  5  grains  (0.30  Gm.),  three  times  daily.  If  the 
weakness  is  prolonged,  strychnine,  1/40  grain  (0.0015  Gm.),  three  times 
daily,  may  be  administered. 

After  the  patient  has  been  restored  to  a  considerable  degree  of 
strength,  he  should  still  be  forbidden  to  return  to  work  too  early.  A 
long  vacation,  if  possible  of  three  to  six  months,  should  be  taken  in 
other  surroundings. 

Prophylaxis.  Typhoid  fever  is  a  preventable  disease.  Its  pre- 
vention awaits  upon  the  overcoming  of  an  inertia.  McCrae  divides 


304  TREATMENT  OF  ACUTE  INFECTIOUS  DISEASES 

the  subject  under  three  heads:  (1)  General  measures,  which  are  for  the 
protection  of  the  community;  (2)  special  measures  in  connection  with 
the  patient;  and  (3)  preventive  inoculation.  The  knowledge  that  the 
disease  is  conveyed  through  the  water,  milk,  food,  especially  oysters  and 
green  vegetables  eaten  raw,  demand  the  supervision  of  the  State  and  the 
community,  through  Boards  of  Health  and  Sanitary  Commissions, 
supervision  of  the  water  supply  with  reference  to  policing  the  water 
sheds,  filtration  plants,  and  all  the  details  dictated  by  sanitary  science. 
It  demands  supervision  of  the  milk  supply,  inspection  of  the  dairies, 
health  of  the  workers,  and  a  consideration  of  sewage  disposal  with  refer- 
ence to  oyster  beds.  It  demands  notification  by  physicians  to  Boards  of 
Health  of  all  cases  of  typhoid  or  suspected  typhoid  fever  occurring  in  a 
community,  and  it  demands  education  of  the  public  through  schools, 
lectures,  and  exhibitions  of  the  part  these  various  factors  play  in  the 
prevention  or  spread  of  the  disease. 

In  connection  with  the  patient  arises  the  question  of  isolation.  Here 
in  New  York,  as  pretty  much  everywhere  else  in  this  country,  typhoid 
fever  is  treated  in  the  same  wards  as  the  general  run  of  cases,  and  we 
assume  from  our  familiarity  with  this  condition  of  affairs  that  there  is  no 
danger  in  the  practice.  It  is  a  little  startling,  then,  to  be  told  that  the 
statistics  of  one  of  the  best  conducted  hospitals  in  this  country  show  that 
from  1.5  per  cent,  to  2  per  cent,  of  the  cases  of  typhoid  fever  treated  in 
this  hospital  are  of  hospital  origin.  I  have  seen  this  thing  occur  in  my 
own  wards,  and  so  has  every  attending  physician,  but  still  our  patients 
are  not  isolated.  As  regards  the  disinfection  of  stools,  urine,  sputum, 
vomitus,  and  care  of  clothing  and  utensils,  all  this  has  been  touched  upon. 
If  we  were  faithful  in  carrying  out  these  measures  in  every  case  of  ty- 
phoid fever,  there  soon  would  be  no  more  cases,  for,  after  all,  the  patient 
is  the  true  source  of  typhoid  fever. 

The  attendants  about  a  patient  are  sources  of  infection  for  others 
unless  conscientious  in  their  cleanliness.  A  great  source  of  danger 
that  might  be  overlooked  are  the  flies,  carrying  the  infectious  material 
direct  on  their  legs  and  bodies  from  the  excreta  to  food  and  water. 
Screens  are  an  obvious  help  in  their  exclusion. 

Carriers.  One  great  menace  to  the  community,  the  handling  of 
which  is  no  easy  problem,  is  the  chronic  bacillus  carrier.  Every  effort 
should  be  made  to  discover  carriers.  That  means  for  one  thing  tracing 
to  its  source  every  case  of  typhoid  and  suspecting  all  food  handlers,  those 
supplying  milk,  green  vegetables,  cooks  and  kitchen  help,  and  recent 
convalescents.  All  suspects  should  have  a  Widal  test  and  have  stools 
and  urine  examined. 

Should  these  be  found  positive  their  families  should  receive  prophy- 


TYPHOID  FEVER  305 

lactic  treatment  with  vaccines  and  means  must  be  taken  to  trace  the 
carrier. 

Some  patients  harbor  for  months  and  years  virulent  bacilli  in  the  urine, 
and  more  commonly  in  the  feces,  from  constant  passage  into  the  bowel 
of  bacilli  from  an  infected  gall-bladder.  Bacilluria  and  its  treatment 
have  been  touched  upon.  Some  day,  perhaps,  Boards  of  Health  will 
demand  to  know  whether  the  stools  of  a  typhoid  fever  patient  are  free 
from  bacilli  before  he  is  allowed  the  freedom  of  the  community,  as  they 
now  demand  to  know  whether  the  Klebs-Loeffler  organism  is  absent 
from  the  secretions  of  diphtheria  patients  before  release  from  quar- 
antine. 

The  use  of  vaccines  for  the  purpose  of  ridding  "carriers"  of  their 
infection  seems  at  the  present  moment  to  hold  out  the  most  promise. 
Cases  of  cure  have  been  reported  in  urinary  "carriers,"  feces  "carriers," 
and  old  bone  lesions. 

The  urinary  cases  have  succeeded  when  hexamethylamin  (urotropin) 
failed.  The  doses  ranged  from  25,000,000  (beginning)  up  to  1,000,000,- 
000  in  six  to  nine  doses  at  four  days  to  one  and  two  week  intervals. 

One  feces  "carrier"  was  reported  cured  by  the  use  of  bacillus  Bul- 
garicus. 

If  a  gall-bladder  carrier  is  suspected  one  may  confirm  the  suspicion  by 
the  use  of  an  Einhorn  tube.  The  tube  is  given  two  hours  after  a  regular 
breakfast. 

The  swallowing  may  be  facilitated  by  having  the  tube  and  sinker  ice 
cold  and  the  patient  in  sitting  posture  and  sipping  small  amounts  of  cold 
water.  Usually  after  four  to  six  hours  the  duodenal  contents  may  be 
expressed  as  an  alkaline  fluid  containing  bile.  It  should  be  sent  at  once 
to  a  laboratory  for  examination  for  the  typhoid  group.  The  magnesium 
sulphate  test  of  Meltzer  would  seem  a  valuable  aid,  in  this  connection. 
Crile  describes  the  technique  thus: — "The  patient  is  given  a  duodenal 
tube  to  swallow  and  the  stomach  contents  are  aspirated  for  a  routine 
examination.  When  this  is  done,  the  patient  is  turned  on  the  right  side 
and  a  pillow  placed  under  the  hips.  He  is  then  instructed  to  massage  the 
epigastric  region  from  the  left  to  the  right  ...  To  relax  the  pyloric 
sphincter  and  thus  facilitate  entrance  to  the  duodenum,  from  20  to 
30  m.  of  benzyl  benzoate  are  given  immediately  after  the  tube  is 
swallowed. 

When  it  is  ascertained  that  the  duodenum  has  been  reached,  usually 
from  three-quarters  of  an  hour  to  an  hour,  a  solution  of  60  c.c.  of  a  25  per 
cent,  solution  of  magnesium  sulphate  is  injected  through  the  tube  into 
the  duodenum.  The  tube  is  then  clamped  and  after  three  or  four  min- 
utes preparation  is  made  to  collect  the  specimen  of  bile.  On  removing 


306  TREATMENT  OF  ACUTE  INFECTIOUS  DISEASES 

the  clamp  of  the  tube  a  flow  of  fluid  is  expected,  usually  with  no  prepara- 
tory aspiration.    This  back  flow  consists  of  a  drip  of 

(1)  A  return  of  part  of  magnesium  sulphate  injected  into  the  duo- 
denum.   This"'  changes  to  '? 

(2)  The  "  common  duct  phase" — bile  of  a  consistency  of  a  thin  syrup. 
After  5  or  10  c.c.  of  bile  of  this  consistency  have  been  cleared  &  definite 
change  is  noted  which  indicates 

(3)  The  " gall-bladder  phase" — bile  of  a  thicker,  more  ropy  consis- 
tency, and  of  a  dark  color,  the  amount  of  which  may  vary  from  25  to 
100  c.c.    The  character  again  changes  to 

(4)  The  "liver  phase" — in  which  the  bile  is  of  a  lighter,  straw  color, 
and  much  more  fluid  in  consistency. 

These  changes  are  quite  definite  and  abrupt.  As  a  routine  measure  no 
aspiration  is  needed,  and  the  outflow  of  bile  occurs  spontaneously.  When 
the  flow  of  bile  ceases,  however,  it  is  always  advisable  to  aspirate  gently 
to  see  if  the  flow  can  again  be  started.  When  flowing  spontaneously 
the  bile  emerges  in  a  series  of  drops  which  ebb  and  flow  like  the  discharge 
from  the  ureter."  (New  York  State  Journal  of  Medicine,  Oct.,  1920, 
p.  335.)  If  positive,  Nichols  recommends  giving  two  grams  of  sodium  bi- 
carbonate three  times  a  day.  In  two  weeks  again  test  the  duodenal  con- 
tents. If  the  alkaline  treatment  is  not  successful  one  may  need  to 
resort  to  vaccines  and,  finally,  surgery. 

One  gall-bladder  "carrier"  was  reported  cured  after  repeated  ex- 
posures of  gall-bladder  to  the  X-ray.  In  some  of  the  gall-bladder  "car- 
riers" only  drainage  of  the  gall-bladder  seemed  successful. 

It  must  be  remembered  as  a  check  upon  enthusiasm  for  any  one 
measure  that  some  of  the  "carriers"  discharge  bacilli  only  intermit- 
tently and  repeated  examinations  at  not  too  short  intervals  must  be 
made  before  certainty  of  a  case  is  assured. 

Preventive  Inoculation.  As  has  been  said,  serotherapy  has  not 
yielded  tangible  results  as  yet,  but  great  results  have  followed  the  pre- 
ventive inoculation  or  vaccination  originated  and  applied  to  the  troops 
of  the  British  army  by  Sir  A.  E.  Wright. 

His  procedure  consisted  in  the  culture  in  bouillon  of  the  organism  for 
four  weeks,  then  killing  at  60°  F.  Different  strains  were  mixed  together, 
standardized,  and  two  injections  made  at  intervals  of  two  weeks  of 
amounts  of  0.5  to  1.5  c.c.,  the  first  containing  about  1,000,000,000 
bacilli,  the  second  2,000,000,000. 

This  was  usually  injected  into  the  flank,  from  which  might  result 
some  redness  and  pain  and  involvement  of  lymph  glands  draining  that 
territory.  There  was  some  constitutional  reaction,  fever,  malaise, 
nausea  and  vomiting,  but  of  no  significance. 


TYPHOID  FEVER  307 

Statistics  seem  to  show  that  among  some  20,000  inoculated  soldiers 
the  incidence  of  disease  and  the  mortality  was  about  one-half  of  that  of 
the  150,000  uninoculated. 

With  certain  improvements  in  technique  made  by  Leishman  of  the 
British  Army  and  by  our  own  Army  Medical  Service  under  Major 
Russell,  antityphoid  inoculation  has  become  the  most  fruitful  and  certain 
preventive  treatment  since  Jenner's  introduction  of  vaccination  against 
small-pox.  Compulsory  inoculation  in  our  army  and  navy  has  for- 
tunately afforded  a  most  convincing  body  of  statistics.  Bodies  of  work- 
ers and  individuals  have  been  quick  to  seize  the  advantage  of  such  a 
measure,  and  it  is  safe  to  predict  that  communities  will  protect  them- 
selves by  compulsory  inoculation. 

Statistics  are  easily  available  for  those  who  are  open-minded. 

I  will  cite  the  published  figures  that  contrast  the  conditions  in  two  great 
Military  Camps,  one  at  Jacksonville  on  the  occasion  of  the  Spanish- 
American  War  in  1898  and  the  other  the  recent  camp  at  San  Antonio 
along  the  Mexican  border. 

Jacksonville,  troops,  10,759.    Cases  of  typhoid,  2,693.    Deaths,  248. 

San  Antonio  troops,  12,801.    Cases  of  typhoid,  2.    Deaths,  0. 

In  Hawaii,  in  Sept.,  1917,  an  epidemic  occurred  along  a  certain  water 
system.  Among  a  population  of  4,087  who  had  been  prophylactically 
vaccinated,  only  55  contracted  the  disease  and  four  died,  while  among 
812  un vaccinated,  45  contracted  the  disease  and  seven  died.  That  is, 
the  incidence  of  the  disease  was  only  four  times  as  great  in  the  unvacci- 
nated  group  and  the  mortality  nearly  9  tunes  as  great.  (Russell.) 

The  experience  of  our  army  in  1917  and  1918  was  most  convincing. 
From  Sept.  1, 1917,  to  May  2, 1919,  in  an  Army  whose  average  strength 
approximated  2,121,396  there  were  213  deaths  from  typhoid.  If  the 
death  rate  of  typhoid  that  obtained  in  the  Civil  War  had  prevailed  the 
deaths  would  have  been  51,133  while  the  death  rate  of  the  Spanish  war 
would  have  raised  the  figures  to  68,164;  one  case  of  typhoid  for  every 
3,756  men  in  the  great  war  and  one  for  every  7  men  in  the  Spanish  war; 
one  death  from  typhoid  among  25,641  men  in  the  great  war;  one  among 
71  in  the  Spanish  war.  (Russell.) 

What  a  triumph  of  Modern  Medicine  these  figures  bespeak ! 

Reliable  vaccine  is  now  supplied  by  various  Health  Boards  and  by 
well-known  pharmaceutical  houses. 

It  is  usual  to  inoculate  in  three  doses  at  ten-day  intervals  (they  may 
be  shortened  to  a  week)  the  first  dose  being  500,000,000,  the  second 
and  third  each  1,000,000,000, 

In  the  army  inoculation  against  paratyphoid  A  and  B  is  made  at  the 
same  time  as  against  typhoid.  It  is  well  to  do  this  in  civil  life.  In  1917 


308  TREATMENT  OF  ACUTE  INFECTIOUS  DISEASES 

in  the  army  there  occurred  13  cases  of  paratyphoid  A  and  7  B  against 
297  cases  of  typhoid.  If  this  proportion  obtains  in  civil  life  the  precau- 
tion is  well  taken.  The  bacillus  paratyphosus  A  and  B  are  each  added 
250,000,000-to  the  500,000,000  of  typhoid  at,the  first  dose  and  500,000,- 
000  each  to  the  1,000,000,000  B.  typhosus  in  the  second  and  third  doses 
or  the  proportion  may  be  750,000,000  each  of  A  and  B  to  1,000,000,000 
of  B.  typhosus.  One  speaks  of  them  as  typhoid  combined  vaccines.  The 
interval  of  administration  may  be  shortened  to  seven  days  or  even  less  in 
emergency.  When  given  every  other  day  the  reaction  is  likely  to  be  more 
severe  and  the  second  dose  the  worse.  At  ten-day  intervals  the  first 
usually  gives  the  worst  reaction. 

It  might  be  said  that  the  New  York  Board  of  Health  supplies  para- 
typhoid vaccine,  the  bacteria  in  the  proportion  of  1,000  million  of  para- 
typhoid A  and  750  million  of  para.  B. 

Reaction  may  occur  in  a  minority  of  cases,  usually  mild,  rarely  severe. 
These  reactions  may  be  local  or  general. 

The  local  induces  a  redness  and  heat  about  the  site  of  the  injection. 
It  rarely  needs  attention,  but  if  discomforting  a  simple  wet  dressing 
may  be  applied. 

The  general  reaction  is  that  of  any  slight  infection;  a  mild  " grippe" 
attack:  Major  Russell  with  his  vast  experience  can  unqualifiedly  pro- 
nounce the  procedure  harmless. 

The  duration  of  immunity  is  placed  by  Russell  at  "assuredly"  two 
and  a  half  years  and  probably  longer. 

This  does  not  mean  that  the  recognized  immune  bodies  last  that 
long  and  Russell  calls  attention  to  the  fact  that  in  cases  of  recovery 
from  typhoid,  though  immunity  usually  lasts  for  life,  "the  immune 
bodies,  nevertheless,  disappear  from  the  blood  of  convalescents  within 
a  few  months."  Russell  has  further  called  attention  to  the  fact  that 
about  one-third  of  deaths  from  typhoid  occur  under  twenty  years;  hence 
accentuates  the  necessity  for  inoculation  of  children. 

Re  vaccination.  In  a  civil  community  very  young  children 
should  be  vaccinated.  It  is  well  to  repeat  this  vaccination  in  later 
childhood,  especially  if  school,  travel  or  work  takes  the  individual  into 
other  communities  of  whose  sanitary  regulation  and  their  enforcement 
little  is  known.  It  might  be  repeated  in  early  adult  life  and  especially 
if  a  typhoid  epidemic  prevails.  This  is  following  much  the  pro- 
cedure advised  in  revaccinations  against  small  pox.  The  supposedly 
more  severe  reactions  in  cases  of  revaccinations  are  probably  ex- 
aggerated. 

Some  observers  have  called  attention  to  the  onset  of  tuberculosis 
and  other  infections  after  inoculation,  but  the  statistics  are  not  con  vine- 


TYPHOID  FEVER  309 

ing  to  me  as  being  anything  more  than  coincidence  or  the  normal  inci- 
dence of  the  disease  in  question. 

An  epidemic  of  typhoid  fever  at  the  Trudeau  Sanitarium  of  Tuber- 
culosis in  1917  gave  us  valuable  information  on  this  point.  All  patients 
in  the  sanatorium  except  those  with  very  active  and  extensive  pulmonary 
lesions  were  inoculated  prophylactically;  134  patients  were  so  treated. 
Without  going  into  the  details  of  the  reaction  I  will  simply  state  that  no 
influence  of  the  vaccines  on  the  progress  of  the  tuberculosis  could  be 
determined. 

Lipovaccines.  These  are  prepared  in  certain  vegetable  oils 
such  as  olive  or  sweet  almond  and  it  is  claimed  for  them  that  they  pro- 
voke less  reaction,  local  or  general,  that  they  admit  of  the  administra- 
tion of  a  sufficiently  large  dose  to  effect  immunity  by  a  single  injection; 
that  they  afford  a  focus  from  which  immunity  proceeds  over  months; 
that  certain  lipoids  having  detoxicating  effects  can  be  incorporated  with 
them  and  that  they  do  not  undergo  autolysis  and  deterioration  (Whit- 
man, Fennel  and  Petersen).  As  much  as  7,500,000,000  can  be  given 
at  a  single  dose. 

Whether  these  advantages  actually  accrue  to  lipovaccines  time  must 
determine. 

To  individuals  going  out  of  their  usual  environment  to  an  unknown 
water  and  food  supply,  antityphoid  inoculation  is  a  wise  procedure. 

SUMMARY 

Rest. 

Bed — how  made.    (See  text.) 

Preparation  for  the  open  air.    (See  Pneumonia,  Chap.  IX.) 

Room — Choice.    (See  text.) 
Screens  against  flies. 

Care  of  the  body. 
Mouth. 
Washes  and  sprays  of  boric  acid  solution,  2  per  cent.,  4  per  cent., 

or  }^2  strength  Dobell's  solution. 
Teeth. 

Brush  two  or  three  times  a  day;  cleanse  interstices,  cotton  on 
wooden  tooth  pick  applicators  saturated  with  boric  acid   or 
Dobell's  solution. 
Tongue. 
Soften  coat  with  Y^/i  strength  peroxide  of  hydrogen  solution, 

scrape  with  edge  of  a  whalebone. 
Pharynx. 
Remove  mucus  with  cotton  swabs  on  applicators. 


310  TREATMENT  OF  ACUTE  INFECTIOUS  DISEASES 

Sordes  and  fissures. 

Soften  sordes  with  Y^/i  strength  of  peroxide  of  hydrogen  solu- 
tion; then  cleanse  with  the  boric  acid  or  Dobell's  solution. 
Use  mild  antiseptic,  e.  g., 

I* 

Phenol  Solution,  1-20 

Glycerin aa  5i  30  c.c. 

Boric  Acid,  saturated  solution, 5  viii        240  c.c. 

M.  et  S.    To  be  used  as  a  mouth  wash. 
Sucking  bits  of  cracked  ice. 
Nose. 

Soften  dried  secretions  with  sweet  oil  on  cotton  on  applicator. 
Cleanse  with  boric  acid  or  Dobell's  solution  id  sprays  or  on  swabs. 
Skin. 

Cleansing  bath  daily,  castile  soap  and  water. 
Use  drying  powder,  talcum. 

Sponge  buttocks  with  equal  parts  of  alcohol  and  water. 
If  buttocks  are  much  soiled,  cleanse  with  phenol  solution,  1  to  40. 
Bed  sores. 

Prevention.     Clean  skin,  dry  skin,  frequent  change  of  position, 
rubbing  of  parts  most  pressed  upon  to  improve  the  circulation. 
Smooth  bed  clothes,  mattress  and  sheets. 
Threatening. 

Use  of  rings. 
Developed. 
Use  rings. 

Use  water  bed  or  air  bed. 
•  Use  drying  powder  on  excoriations,  e.  g.,  aristol,  or 

Use  ointment  such  as  zinc  oxide  ointment. 
Serious  sores. 

Surgery. 
Disinfection. 
Stools. 

One  to  20  phenol  (carbolic  acid).  Use  twice  the  bulk  of  the  stool, 
break  up  the  stool,  allow  it  to  stand  in  the  solution  for  several 
hours. 

Chlorinated  lime  (must  be  fresh)  1  per  cent,  solution  or  a  handful 
in  a  bed  pan  with  enough  water  to  cover  stool.     Let  it  stand 
several  hours. 
Urine. 

One  to  20  phenol,  using  1/3  to  equal  amounts  with  urine. 

Let  stand  two  or  more  hours. 

One  to  1,000  bichloride  in  volume  equal  to  1/15-1/40  of  the  urine. 

Let  stand  two  or  more  hours. 
Bath  water. 

Half  pound  of  chlorinated  lime  to  one  tub  (200  litres).    Stand  an 

hour. 
Bed  linen. 

One  to  20  phenol — soak  two  hours,  or  formalin  3  ounces  to  1  gallon 
(100  c.c.  to  4  litres),  soak  twelve  hours,  boil  thoroughly. 


TYPHOID  FEVER  311 

Bed-pans,  urinals,  rectal  tubes,  rubber  sheets,  1  to  20  phenol;  allow  to 

stand  in  it. 

Knives,  forks,  spoons,  crockery.    Boil. 
Sputum.    Burn. 
Vomitus. 

One  to  20  phenol. 

1  per  cent,  chlorinated  lime. 

Precautions  for  physicians  and  nurses. 

Wear  rubber  gloves  and  aprons  in  giving  baths,  and  wash  hands 
later  with  soap  and  water  and  with  1  to  1,000  bichloride  of  mer- 
cury. 

End  of  illness. 
Mattresses. 

Dry  heat — (not  practical  at  home). 
Room. 
Formaldehyde  gas. 

Diet. 

Aim  at  3,000  calories  (40  calories  per  kilo)  in  early  weeks  and  more 
in  latter  weeks,  as  much  more  as  the  patient  wishes  or  will  take  and 
handle  well. 

Proteid — 70  to  90  grams. 

Carbohydrates  the  mainstay  (the  protein  shelterer). 
Fats  fairly  liberally. 
Frequency  of  feeding. 

Every  two  hours.  Some  patients  will  do  better  at  longer  inter- 
vals. It  is  better  not  to  disturb  the  patient's  night's  rest  for 
feeding. 

Milk,  the  basis  of  the  dietary — 1  to  2  quarts  a  day. 
Caloric  value — 640  to  the  quart,  one  glass  of  8  ounces  equals  160 

calories. 

Milk  enriched  by  cream  and  milk  sugar. 
Cream — 16  per  cent,  gravity,  50  calories  per  ounce. 
Lactose — 120  calories  per  ounce. 
One  glass  containing  milk,        7  ounces,  140  calories, 
cream,     1  ounce,     50  calories, 
lactose,  %  ounce,     60  calories. 


Equals  250  calories. 


One  glass  containing  milk,  6  ounces,  equals  120  calories, 
cream,  2  ounces,  equals  100  calories, 
lactose,  }^  ounce,  equals  60  calories. 

Equals  280  calories. 


312 


TREATMENT  OF  ACUTE  INFECTIOUS  DISEASES 


One  glass  containing  milk,  6  ounces,  equals  120  calories, 
cream,  2  ounces,  equals  100  calories, 
lactose,  1  ounce,  equals  120  calories. 

Equals  340  calories. 


Eggs  may  be  given  up  to  4,  5,  or  6  a  day. 

One  egg  equals  80  calories. 

One  egg  white  equals  30  calories. 

One  egg  yolk  equals    50  calories. 

May  be  given  soft  boiled,  coddled,  or  raw,  or  in  soft  or  baked 

custard,  or  eggnog. 
Bread,  white,  home  made,  equals  1,225  calories  to  1  pound. 

One  slice,  \Y±  ounces,  equals         100  calories. 

Given  as  toast,  milk  toast,  bread  and  butter,  bread  and  milk. 
Butter  equals  3,600  calories  to  1  pound. 

One  pat  of  butter  (2/5  ounce)  equals  100  calories. 

Put  on  bread  and  cereals. 

Cereals — vary  somewhat,  but  one  helping  of  two  heaping   table- 
spoonfuls  equal  about  100  calories. 

Rice — one  heaping  tablespoonful  equals  100  calories. 

Potato — baked  (medium)  equals  100  calories. 

Potato — mashed,  \y%  tablespoonfuls,  100  calories. 

Table. 

Milk — one  glass,  8  ounces,  160  calories. 

Cream — one  ounce,  50  calories. 

Sugar — one  ounce,  120  calories. 

Egg — one,  80  calories. 

Bread,  one  slice,  1J4  ounces,  100  calories. 

Butter,  one  pat,  2/5  ounce,  100  calories. 

Cereals,  two  heaping  tablespoonfuls,  100  calories. 

Rice,  one  heaping  tablespoonful,  100  calories. 

Potato,  baked,  one,  100  calories. 

Potato,  mashed,  1}^  tablespoonfuls,  100  calories. 

Crackers,  Boston,  one,  42  calories. 

Oysters,  ten,  48  calories. 

Pilot  bread,  one,  131  calories. 

Soda,  Educators,  one,  10  calories. 

.  Uneeda  biscuits,  one,  25  calories. 
Ice-cream  (average)  2  heaping  tablespoonfuls,  200  calories. 

Baked  custard,  2  heaping  tablespoonfuls,  180  calories. 

Soft  custard,  4  heaping  tablespoonfuls,  130  calories. 

Bread  pudding,  2  heaping  tablespoonfuls,  225  calories. 

Koumyss,  one  glass,  7  ounces,  100  calories. 

Buttermilk,  one  glass,  80  calories. 

Whey,  one  glass,  50  calories. 

Apple  sauce,  one  ounce,  50  calories. 

Macaroni,  2  heaping  tablespoonfuls,  100  calories. 


TYPHOID  FEVER 


313 


Cocoa,  one  rounding  teaspoon,  5  grains,  25  calories. 

Cracker,  Uneeda,  one  25  calories. 

Egg  white,  one  egg,  30  calories. 

Egg  yolk,  one  egg,  50  calories. 

Orange,  one  large,  100  calories. 

Among  other  articles  may  be  mentioned  tea,  coffee,  cocoa  to  carry 

sugar  and  cream;  lemonade,  orangeade,  wine  jelly  to  carry  sugar. 
Chicken,  veal  or  mutton  broth  to  stimulate  an  appetite;  thickened 

with  rice,  barley,  arrowroot  to  add  calories. 
Potato,  pea  and  tomato  soup,  junkets. 

Sample  diet  modelled  on  Coleman  list,  avoiding  night  feeding. 
Milk,        7  ounces,  ] 

Cream,     1  ounce,  j-  equals  250  calories,  at  5  a.  m.  250. 

Lactose,  Bounce,  J 

80  calories. 
100  calories. 
150  calories. 
100  calories. 


Egg,  one, 

Toast,  two  thin  slices, 

Butter,  \y<t  pats, 

Coffee  with  cream,  2  ounces, 

Lactose,  2/3  ounce, 


Milk  as  above, 


80  calories. 
510  calories. 


at  7  a.  m. 


510. 
at  9  a.  m.      250. 


Egg,  one,  80  calories. 
Mashed  potato,  Y^  tablespoonful,  30  calories. 
Baked  custard,  2  heaping  table- 
spoons, 180  calories. 
Toast  or  bread,  two  small  slices,  100  calories. 
Butter,  V/i  pats,  150  calories. 
Coffee,  cream,  2  ounces,  100  calories. 
Lactose,  %  ounce,  80  calories. 

720  calories. 
Milk  as  above, 
Milk  as  above, 

Egg,  one,  80  calories. 

Cereal,  3  tablespoonfuls,  150  calories. 

Cream,  2  ounces,  100  calories. 


Sugar  (powdered),  1  heaping  tea- 
spoonful, 

Apple  sauce,  1  ounce, 
Tea,  cream,  2  ounces, 
Lactose,  2/3  ounce, 


Milk  as  above, 
Milk  as  above, 


50  calories. 
50  calories. 
100  calories. 
80  calories. 

610  calories. 


at  11  a.  m. 


at  1  p.  m. 
at  3  p.  m. 


at  5  p.  m. 


at    7  p. 
at  10  p. 


720. 
250. 
250. 


610. 

m.    250. 
m.    250. 


Total  3,340. 


314  TREATMENT  OF  ACUTE  INFECTIOUS  DISEASES 

Drinks. 

Water  ad  libitum;  offer  hourly  when  patient  does  not  ask  for  it,  or 
alkaline  waters,  lemonade  and  orangeade  and  Imperial  drink,  to 
which  the  addition  of  sugar  increases  the  caloric  intake. 

Two  to  three  quarts  of  fluid  daily  and  more  if  patient  will  take  it. 

Avoid  slavish  adherence  to  exact  dietaries. 

Vary  the  food  to  avoid  monotony. 

Increase  calories  in  decline  of  fever. 

Add  chicken,  fish,  meat,  and  vegetables  in  convalescence;  begin  with 
chicken  or  scraped  beef,  when  temperature  is  normal  or  nearly 
so,  and  add  other  articles  gradually  and  tentatively,1  such  as  chops, 
spinach,  asparagus  tops,  peas,  and  stringed  beans  put  through  a 
puree  sieve. 

Hydrotherapy. 

Brand  bath.    (For  technique,  see  text.) 
Ziemssen's  graduated  bath.    (See  text.) 
Slush.    (See  text.) 
Packs. 
Sponges. 

Care  of  alimentary  canal. 
When  first  seen  early. 

Castor  Oil  (Oleum  ricini)  ...............  5%  to  1  (20-30  c.c.). 

Epsom  Salt  (Magnesium  sulphate)  .......  %%  to  1  (20-30  Gm.). 

Rochelle  Salt  (Sod.  et  Pot.  tartrate)  .....  %%  to  1  (20-30  Gm.). 

or 
Calomel  (Hydrargyri  chloridum  mite),  gr.  %  (0.015  Gm.)  every 

quarter  hour  for  6  doses  and  followed  by  one  of  the  above. 
Later  and  if  seen  late. 
Enemata  of  tepid  water. 
Soapsuds  —  use  castile  soap. 
Oil  enema. 

Make  thick  suds  with  castile  soap  and  warm  water,  stir  in  oil 
slpwly,  then  add  water  .to  1  or  2  pints. 

Tympanites. 

Suspect  milk  sugar,  cut  it  down  or  eliminate  it. 
Rectal  tube. 
Stupes.    (See  text.) 
Turpentine. 
In  stupes. 


In  Capsule  or  Emulsion,  m.  x. 
1  For  caloric  values  of  foodstuffs  consult  tables  of  Atwater  and  his  co-workers 
issued  by  U.  S.  Department  of  Agriculture. 
Food  Values  by  Edwin  Locke. 

Tables  of  Prof.  Irving  Fisher  in  J.  A.  M.  A.    April  20,  1907. 
Tables  of  Arnold  in  J.  A.  M.  A.    December  24,  1910. 
Coleman  in  Articles  referred  to. 


TYPHOID  FEVER  315 


Ice  bag. 
Ice  coil. 


Milk  and  molasses  enema. 
Each  eight  ounces,  warm. 

Peppermint  enema. 

3i  to  3ii  to  quart  saline. 

Pituatrin,  minims  5-15. 
(0.33-1  c.c.). 

Diarrhea. 

Suspect  fat. 

Cut  down  or  eliminate. 

Boiling  milk  may  help. 

May  have  to  stop  milk. 

Saline  irrigation,  sodium  chloride  3i  (4  Gm.)  to  1  pint  (500  c.c.), 

prolonged. 
Murphy  drip. 
Astringents. 

Bismuth  subnitrate,  gr.  xxx  (2  Gm.)  every  three  or  every  two 
hours. 

Opium  if  imperative,  pill,  gr.  J^  (0.030)  every  two  hours  for  2, 
3  or  4  doses. 

I* 

Pulv.  Opii 0.25         (gr.  iii%) 

Pulv.  Camphorae 1 . 00         (gr.  xv 

Plumbi  Acetatis 3.00         (gr.  xlv) 

Bismuth  Subnitratis 30.00         (5i) 

M.  et  Div.  in  chartulas  no.  xv. 
S.    One  every  4  hours. 

Gastric  distress. 
Suspect  both  fat  and  lactose.    Cut  down  or  eliminate. 

Vomiting. 

Cracked  ice,  sucked. 

Mustard  paste  to  epigastrium  (1  in  4). 

Bismuth  subnitrate gr.  xv-xxx  (1-2  Gm.). 

Sodium  bicarbonate gr.  x-xx  (0.66-1.33  Gm.). 

Cerium  pxalate gr.  iii-v  (0.20-0.30  Gm.). 

or  combine 

Bismuthi  Subnitratis 15         (5ss.) 

Sodii  Bicarbonatis 10         (3iiss.) 

Cerii  Oxalatis 5         (3i  M) 

M.  et  Div.  in  chart  no.  xv. 

S.    One  every  two  hours  (in  the  food  if  given). 


316  TREATMENT  OF  ACUTE  INFECTIOUS  DISEASES 

If  very  severe. 

Cocaine  hydrochloride  —  tablet,  gr.  1/5  (0.010  Gm.),  or  1/10  per  cent. 
solution  5i  (4  c.c.)  every  two  hours. 

Stomach  washing,  lavage. 

•»»•  >t 

Hemorrhage. 

Early  stages,  oozing,  no  treatment. 

Serious  latter  part  of  second  and  third  week. 

Mild. 

Cut  down  food. 

Enjoin  rest. 
Moderately  severe. 

Ice  bag  to  abdomen. 

Calcium  lactate,  gr.  x  (0.60  Gm.)  three  times  a  day. 

Horse  serum,  10-20  c.c.    To  avoid  anaphylaxis  in  use  of  serum. 
(See  text.) 

Human  serum,  10-20  c.c. 

Thro  mboplastin. 

20  c.c.  in  water  gviii  several  times  a  day  by  mouth. 
Severe  with  symptoms  of  hemorrhage.    (See  text.) 

Morphine  sulphate  hypodermically  or  intramuscularly,  gr.  %  (0.015 

Gm.). 
Exsanguination. 

Elevate  foot  of  bed. 

Heat  to  extremities. 

Physiological  salt  solution  (3i-Oi)  (4  Gm.-500  c.c.)  hot  in  the 
bowel. 

Hypodermoclysis  of  same,  or  Ringer's  solution. 

Infusion  of  same  into  vein. 

Best  of  all,  transfusion.    (See  text.) 

Perforation.    (For  symptoms,  see  text.) 
Surgical  intervention. 

Nervous  system. 

Headache. 

Ice  bag. 
Sleeplessness. 

Less  marked  with  the  Brand  bath  and  sufficient  diet. 

Bromides. 

Bromide  of  potash,  gr.  xv-xxx  (1-2  Gm.). 

or 


Potassii  Bromidi. 

Aimnonii  Bromidi. 

Sodii  Bromidi  ............................  aa       5.00          (gr.  Ixxx) 

Aquae  destillatae  ...................  q.  s.  ad     60.00         (gii) 

M.  et  S.  3i  in  water.    Repeat  in  two  hours  if  needed. 


TYPHOID  FEVER  317 

TrionaJ — gr.  xv-xx  (1-1 .30  Cm.) .    In  a  little  warm  water  or  in  whiskey, 
brandy  dr  wine  or  in  powder;  wash  down  with  water. 
Repeat  in  two  hours  if  needed. 
Chloralamid— gr.  xx-xxx  (1.30-2  Gm.). 
In  cold  water  (not  hot),  in  wine,  whiskey,  or  brandy,  or  in  powder 

and  wash  down  with  water. 
Repeat  if  needed  in  two  or  three  hours. 
If  marked  or  prolonged. 
Morphine  sulphate,  gr.  1/16-1/4  (0.005-0.015  Gm.). 

D  elirium — Restraint. 

Cold  baths. 

Tepid  baths  with  cold  water  to  head. 

Ice  bag  to  head. 

Morphine  hypodermically,  gr.  1/8-1/4  (0.008-0.015  Gm.). 

Lumbar  puncture. 

Draw  off  20  c.c.  or  even  more. 

(For  technique,  see  Cerebro-Spinal  Meningitis,  Chap.  XXV.) 

Stupor. 

Cold  baths. 
Tepid  baths. 
Ice  bag  to  head. 
Lumbar  puncture. 

Circulatory  disturbances. 

(For  symptoms,  see  text.) 
Prevention. 
Sufficient  diet. 
Cold  baths. 
Fresh  air. 
Failing  circulation. 
Digitalis. 

Infusion  5ss.  (15  c.c.)  three  times  a  day, 

or  tincture  m.  xxx  (2  c.c.)  three  times  a  day  for  three  or  four  days, 
or  longer  until  improvement  in  the  circulation  is  seen  or  accumula- 
tion is  evidenced.    (See  text.) 
In  urgent  circulatory  distress. 

Strophanthin  (Boehringer's)  (0.0005-0.00075  Gm.)  (gr.  1/120-1/90) 

intramuscularly  or  intravenously,  and  then  follow  with  digitalis 

as  above,  or  crystalline  strophanthin  (ouabain)  1/2  to  3/4  the 

above  dose. 

When  either  therapeutic  or  toxic  effect  is  severe,  stop  using  for  three 

or  more  days,  and  repeat  if  needed. 
Another  method  (less  satisfactory). 
Digitalis  infusion  3i~ii  or  tincture  m.  x  three  times  a  day  may  be 

given  without  interruption  unless  the  stomach  is  irritated. 
If  satisfactory  results  do  not  ensue,  or  for  any  reason  (idiosyncrasy) 
digitalis  cannot  be  taken, 


318  TREATMENT  OF  ACUTE  INFECTIOUS  DISEASES 

Vasomotor  stimulants. 

Caffeine   sodium   salicylate  or  caffeine   sodium   benzoate,   gr.   v 

(0.35  Gm.)  into  muscle  every  four,  three  or  two  hours. 
Camphor  in  oil  10  per  cent,  or  20  per  cent.,  gr.  v  (0.35  Gm.)  every 
four,  three  or  two  hours,  or  alternate  at  every  two-hour  intervals 
the  caffeine  and  the  camphor  in  gr.  v  (0.35  Gm.)  doses. 
Strychnine  sulphate  (less  valuable),  gr.  1/60-1/30  (0.001-0.002  Gm.) 
every  three  or  four  hours.    Given  hypodermically. 

Threatened  collapse. 

Adrenalin  (Epinephrin)  m.  xv  (1  c.c.),  into  a  muscle  or  m.  iii-iv 
(0.20  c.c.)  into  a  vein.  Follow  by  caffeine  or  camphor  in  gr.  v 
(0.35  Gm.)  doses  into  muscle  and  by  strophanthin  1/2  mg.  (gr. 
1/120)  into  muscle  or  vein. 

Urinary  tract. 

Bacilluria. 

Urotropin  as  a  routine. 

Begin  as  temperature  approaches  normal  and  continue  for  a  month 
after,  gr.  v-x  (0.30-0.60  Gm.)  three  times  a  day  for  three  con- 
secutive days  each  week. 
If  urine  is  alkaline,  add  benzoate  of  sodium  or  ammonium,  gr.  x 

(0.60  Gm.)  to  each  dose  of  urotropin. 
If  this  does  not  clear  it  up  use 

Bladder  injections  of  silver  nitrate  1-5,000  solution  daily, 
or  saturated  boric  acid  solution  daily. 

Vaccine  therapy. 

Intravenous:  initial  dose  25  to  50  million  diluted  to  1  c.c.  (For  inter- 
vals and  reactions,  see  text.) 

Complications. 

Phlebitis. 

Rest — fixation  relative  or  absolute. 

Enclose  in  non-absorbent  cotton. 

Wet  dressings — Aluminium  acetate. 

Poultices.    (See  Pneumonia,  Chap.  IX.) 
Meningismus. 

Tapping. 
Meningitis. 

(See  Cerebro-Spinal  Meningitis,  Chap.  XXV.) 

Convalescence. 

(See  diet  in  Summary.) 

After  temperature  is  normal,  seven-ten  days. 

Prop  up  in  bed:  three  to  four  days  more. 

Sit  up  in  chair,  a  little  longer  each  day,  after  a  week  get  on  feet. 

If  temperature  rises,  consider  bowels;  too  much  meat  too  early. 


TYPHOID  FEVER  319 

Get  out  in  sun  and  air. 

Watch  bowels. 

Mild  cathartics  such  as  cascara,  aloin. 

Treat  anaemia. 

Blaud's  pill  (Pil.  ferri  carb.)  gr.  v  (0.35  Gm.)  three  times  a  day. 
For  weakness. 

Strychnine  sulphate,  gr.  1/60-1/30  (0.001-0.002  Gm.)  three  times 
a  day, 

or  tincture  of  nux  vomica  m.  x-xv  (0.60-1  c.c.)  three  times  a  day. 
Do  not  return  to  work,  or  admit  business  matters  too  soon. 
Long  vacation  of  three  to  six  months. 

Prophylaxis. 

Protection  of  community. 
Supervision  of  water  supply. 


Boards 

of 
Health 

and 

Sanitary 
Commis- 


Filtration  plants.    Policing  water  sheds. 

Supervision    of    milk    supply;    inspection    of    health   of 

workers.    Inspection  of  drains. 

Inspection  of  oyster  beds.    Inspection  of  green  vegetables. 
Sewage  disposal. 
Notification  of  cases. 


Schools. 
Exhibitions. 
The  patient. 
Isolation. 

Disinfection  of  all  discharges  and  clothes  and  utensils.    (See  above.) 
Preventing  access  of  flies  by  screens. 
Care  on  part  of  attendants. 
Treatment  of  "carriers." 

Prophylactic;  urotropin  as  above. 

Inspection  of  urine  and  stools  of  convalescents  for  the  organisms. 
Vaccines  for  all   "carriers,"   beginning  25,000,000,   work  up   to 

1,000,000,000,  four  to  seven  day  intervals,  in  six  to  nine  doses. 
May  try  for  feces  "carriers," 

Bacillus  Bulgaricus  by  mouth;  or  by  rectum  in  small  amount  of 

sugar  solution,  2  per  cent. 
Gall-bladder  "carriers." 

X-ray  cure  has  been  reported. 

Drainage  of  gall-bladder  has  been  necessary  and  has  cured. 
Diagnosis  established  by  Einhorn  tube.     Sodium  bicarbonate,  2 
grams  three  times  a  day.     (See  text.) 

Preventive  inoculation,  for  typhoid. 

1st  dose.  500,000,000. 

After  7  to 

10  days.    2nd  dose.         1,000,000,000. 
After  7  to 
10  days.     3rd  dose.         1,000,000,000. 


320  TREATMENT  OF  ACUTE  INFECTIOUS  DISEASES 

Preventive  inoculation  for  paratyphoid. 

First  dose  500  million  of  Para  A 
375    "        "     "     B 

After  7  to  10  days  second  dose.  ., 

These  are  often  combined  in  the  proportion  of  1  billion  to  typhoid  and 

750  million  each  of  paratyphoid  A  and  B  per  c.c. 
First  dose,  one  half  c.c.  and  the  second  and  third,  1  c.c.  at  7-10  day 

intervals. 

PARATYPHOID   FEVER 

Until  bacteriological  research  determined  the  identity  of  the 
paratyphoid  organism  the  clinical  entity  was  submerged  in  the  picture 
of  typhoid  fever.  In  the  vast  majority  of  cases  this  infection  of  low 
mortality,  not  more  than  1  per  cent.,  was  considered  as  a  light  typhoid  of 
short  duration  and  it  is  doubtful  if  it  ever  would  have  been  distinguished 
on  clinical  grounds  alone,  for  its  symptomatology  is  almost  identical 
with  that  of  typhoid;  a  prolonged  fever,  slow  pulse,  rose  spots,  enlarged 
spleen,  hemorrhages,  leucopenia,  tympanites.  No  symptom  is  distinctive. 
The  fever  is  as  a  rule  less  high  and  less  prolonged,  the  hemorrhages  are 
less  profuse,  perforations  are  very  rare;  but  what  is  all  this  but  the 
picture  of  a  light  typhoid?  The  complications  are  the  same,  such  as 
meningitis,  thrombophlebitis,  cholecystitis  and  pyelitis,  but  the  latter 
and  pyelonephritis  and  cystitis  are  stubborn  in  their  persistency  and 
the  discharge  of  bacteria  long  continued. 

Pulmonary  complications  including  a  considerable  percentage  of 
pneumonias,  often  with  pleurisy  and  sometimes  with  empyema,  are 
not  uncommon.  The  bacillus  paratyphosus  may  be  recovered  from 
the  sputum..  Such  cases  are  often  looked  upon  as  purely  pulmonary; 
the  paratyphoid  infection  being  overlooked. 

Gastro-intestinal  symptoms,  too,  are  likely  to  be  more  marked  and, 
indeed,  this  infection  may  present  the  picture  of  acute  gastro-enteritis 
and  even  of  cholera. 

Relapses  are  rare. 

The  organisms  concerned  are  two  types  of  bacilli  called  bacillus 
paratyphosus  A  and  bacillus  paratyphosus  B.  The  former  produces 
acid  on  suitable  media  and  the  latter  alkali.  Paratyphoid  B  is  a  far 
more  common  agent  than  A  hi  the  production  of  the  disease.  Para- 
typhosus B  has  so  many  points  in  common  with  the  bacillus  enteritidis 
of  Gartner  that  the  differentiation  depends  largely  on  agglutinating 
properties. 

Infection  is  conveyed  by  the  feces  and  urine,  through  contaminated 
food  and  the  careless  handling  of  infected  excretions.  Paratyphoid  B 
at  least  seems  also  to  be  transmitted  through  infected  meat. 


TYPHOID  FEVER  321 

The  diagnosis  lies  in  the  determination  of  the  bacillus  in  blood,  stool 
or  urine  cultures  and  in  agglutination  reactions  (Widal).  It  is  the  only 
way  to  distinguish  between  typhoid  fever  and  paratyphoid  fever  and 
the  agglutination  and  cultural  characteristics  of  bacillus  A  &  B  alone 
distinguish  the  one  infection  from  the  other. 

The  pathology  shows  the  same  implication  of  the  lymphoid  tissues 
in  most  cases  as  in  typhoid,  the  same  ulcerations,  but  perhaps  more 
superficial. 

Treatment  is  in  all  respects  like  that  in  typhoid  fever. 

Under  that  heading,  too,  will  be  found  a  discussion  of  prophylactic 
vaccination  in  paratyphoid. 


CHAPTER  XV 

MALARIA 

FROM  the  barks  of  the  various  species  of  cinchona  is  derived  an  al- 
kaloid, called  quinine,  and  this  quinine  is  more  truly  a  specific  than 
any  other  drug  in  the  whole  pharmacopeia. 

The  treatment  of  malaria  resolves  itself  pretty  much  into  the  skillful 
use  of  quinine. 

The  r61e  of  the  mosquito,  the  anopheles,  the  varieties  of  the  lowly 
order  of  animal  life,  the  sporozoan  protozoa  (the  plasmodium  vivax, 
or  tertian  parasite,  the  plasmodium  malarise  or  quartan  parasite  and 
the  plasmodium  falciparum  or  estivo-autumnal  or  malignant  parasite), 
the  stereotyped  manifestations  of  chill,  fever  and  sweat  and  the  inter- 
mittent or  remittent  temperature  in  malarial  infection  are  familiar  to 
us  all. 

It  is  only  within  the  last  three  or  four  years  that,  thanks  to  the  labors 
of  Bass,  the  cultivation  of  the  malarial  organisms  has  become  possible 
and  undoubtedly  much  light  of  therapeutical  value  will  be  shed  on  the 
problem  by  him  and  those  who  are  using  his  methods. 

While  we  are  interested  in  the  differentiation  of  the  manifestations 
of  the  disease,  into  the  tertian,  quartan  or  estivo-autumnal  forms,  as 
based  on  the  variety  of  the  invading  organism,  the  degrees  of  severity, 
after  all,  depend  not  a  little  on  where  the  infection  occurs  as  well  as  on 
what  organism  is  present.  In  the  Northern  States  we  have  to  treat 
relatively  mild  cases;  in  the  South  much  more  severe  and  some  pernicious 
types;  and  in  the  tropics  many  pernicious  cases.  The  lighter  cases, 
such  as  predominate  in  the  North,  are  due  to  the  benign  tertian  parasite, 
plasmodium  vivax,  and  much  more  rarely  the  quartan  plasmodium 
malariae,  causing  intermittent  fevers,  while  the  tropical  fevers  are  more 
commonly  due  to  the  malignant  tertian,  estivo-autumnal  organism, 
p.  falciparum,  causing  a  remittent  type  of  fever.  However,  here  in  the 
North  one  rarely  sees  the  pernicious  types  of  infection,  algid,  comatose, 
though  estivo-autumnal  forms  are  frequently  met  with. 

Considering  first  the  milder  cases  as  seen  here  in  the  North,  some  of 
them  are  so  slight  that  the  patient  may  object  to  going  to  bed.  The 
ordinary  attack,  however,  compels  the  patient  to  seek  rest. 

In  any  case  our  results  are  better  when  the  patient  does  go  to  bed 
and  is  made  to  observe  rest. 


MALARIA  323 

Rest.  The  difference  between  the  appearance  of  the  shaking, 
fevered  or  sweating  patient  of  one  day  and  the  apparently  well  individual 
of  the  next,  is  one  of  the  most  striking  contrasts  of  medicine. 

During  the  period  of  intermission,  the  patient  feels  so  well  that  he 
will  often  rebel  against  remaining  in  bed  and  greets  his  physician  sitting 
up  and  dressed  on  the  occasion  of  his  next  visit. 

In  the  milder  cases,  no  strenuous  objection  to  this  performance  need 
be  voiced;  but,  if  the  paroxysm  has  been  severe,  the  patient  should  be 
assured  that  his  remaining  at  rest  facilitates  success  in  aborting  the 
second.  In  the  remittent  estivo-autumnal  forms  it  should,  of  course, 
be  insisted  upon.  Each  individual  paroxysm  means  an  intoxication, 
and  as  the  result  of  this  and  the  marked  pyrexia  accompanying  it,  tissue 
destruction  has  been  entailed  which  makes  all  the  more  imperative  the 
economy  in  the  body's  energies  accomplished  by  rest  of  the  tissues 
attacked  by  the  organism.  The  one  tissue  in  which  a  gross  lesion  occurs, 
is  the  red  blood-cell  and  its  destruction  induces  a  degree  of  anemia. 
Now,  in  untreated  cases  or  badly  treated  cases,  emaciation  and  anemia 
of  a  marked  grade  ensue  and  the  necessity  for  rest  is  as  urgent  as  in 
other  infections  of  long  continuance.  With  prompt  treatment  this  does 
not  obtain,  and  after  an  anticipated  paroxysm  fails  to  appear  the  patient 
may  be  allowed  to  get  up. 

Bed.  On  account  of  the  brevity  of  the  attack,  when  well  treated 
one  may  be  less  insistent  on  the  nicety  of  details  with  reference  to  the 
bed  than  in  the  infectious  diseases  of  longer  continuance,  if  it  entails 
extra  expense  in  the  procuring;  but  in  severe  cases,  in  pernicious 
types  with  continued  fever,  we  economize  the  strength  both  of  the 
patient  and  attendant  and  enhance  the  success  of  our  treatment  if  an 
iron  half-bed  with  woven  wire-springs  and  firm  mattress,  which  is 
best  illustrated  by  the  hospital  bed,  is  used. 

Room.  If  the  patient  is  still  in  a  malarious  district  his  room 
should  be  so  chosen  that  the  chances  of  further  infection  are  lessened. 
By  selecting  one  in  the  upper  part  of  the  house,  since  the  invasion  by 
the  mosquito  is  less  likely,  and  making  doubly  sure  by  the  use  of  screens 
or  mosquito  netting,  this  object  is  accomplished.  This,  too,  affords 
a  certain  protection  to  attendants. 

In  other  respects  the  room  should  be  chosen  in  severe  cases  accord- 
ing to  the  same  criteria  that  obtain  in  other  acute  infections,  with  a 
view  to  size,  ventilation,  light,  access  to  the  open  air  by  veranda  and 
nearness  of  bath  room,  simplicity  of  furnishings  and  remoteness  from 
disturbing  elements  of  the  household. 

Diet.  The  suddenness  of  the  attack,  the  anorexia,  nausea  and 
vomiting  contraindicate  any  effort  at  nourishment  during  the  paroxysm. 


324  TREATMENT  OF  ACUTE  INFECTIOUS  DISEASES 

During  the  afebrile  periods  of  the  intermittent  type  of  fever,  semi-solid 
or  solid  food  of  a  simple  character  may  be  taken,  but  at  any  meal  occur- 
ring within  six  hours  of  the  anticipated  recurrence  of  the  paroxysm  the 
food  should  -be  fluid  or  semi-solid,  as  milk,  eggs,  cereals  or  toast.  This 
is  in  consequence  of  the  vomiting  that  may  ensue. 

It  is  interesting  to  note  that  Bass  and  Johns  in  their  studies  on  the 
culture  of  the  plasmodium  observed  that  the  blood  seemed  to  form  a 
better  culture  medium  immediately  after  a  full  meal  and  this  they  say 
corresponds  with  the  clinical  fact  that  the  parasites  will  often  disappear 
from  the  blood  and  the  paroxysms  cease  if  the  patient  is  put  to  bed  and 
given  a  purgative  and  put  on  a  light  diet. 

If  the  fever  is  of  the  remittent  type,  the  same  precautions  should 
be  observed  at  the  periods  of  paroxysm,  but  in  the  intervals  the  diet, 
while  it  should  be  somewhat  restricted  in  the  choice  of  food,  should 
nevertheless  contain  sufficient  nutritive  value  in  terms  of  calories  and 
protein. 

Care  of  the  Bowels.  Calomel  should  be  given  either  in  one 
dose  of  gr.  iii-v  (0.20-0.33  Gm.)  or  in  divided  doses  of  gr.  %  (0.015 
Gm.)  every  }/£  hour  for  six  or  eight  doses,  and  this  may  be  followed  in 
3  to  4  hours  by  a  saline.  The  best  time  to  give  the  cathartic  is  between 
the  paroxysms.  It  should,  however,  precede  the  quinine  when  possible. 

SYMPTOMATIC  TREATMENT  DURING  THE  PAROXYSM 

The  phenomena  of  the  paroxysm,  chill,  fever,  and  sweating  have 
been  looked  upon  as  the  expression  of  the  action  of  a  toxin  released  by 
the  plasmodia  at  the  time  of  sporulation,  but  Wade  Brown  from  his 
recent  studies  concludes  that  they  are  all  in  part  at  least  due  to  the  toxic 
action  of  the  malarial  pigment,  that  is,  hematin,  derived  from  the 
destroyed  red  blood  cells.  The  three  stages  of  the  paroxysm  are  each 
provided  with  their  own  particular  form  of  discomfort  for  the  patient 
and  demand  pretty  constant  attention  and  ministration  to  mitigate 
their  evils. 

Chill.  Beginning  with  chilly  sensations,  followed  by  shiverings 
and  then  shakings,  with  the  skin  covered  with  "goose-flesh,"  pale, 
cyanotic,  the  face  pinched  and  the  teeth  chattering,  the  patient  can  only 
complain  of  the  cold  and  beg  for  warmth. 

One  does  everything  possible  to  afford  this,  by  putting  hot-water 
bottles  to  the  feet,  wrapping  flannel  about  the  extremities,  heap- 
ing on  blanket  after  blanket  and  giving  hot  drinks,  hot  water, 
weak  tea,  hot  weak  milk,  into  which  a  dash  of  ginger  may  be 
stirred,  hot  lemonade,  a  little  hot  whiskey  or  brandy. 


MALARIA  325 

The  discomforts  may  be  mitigated  by  the  use  of  codeine  phosphate 
in  half  grain  (0.033  Gm.)  doses  by  mouth  or  spirits  of  chloroform  in 
one  dram  doses. 

Vomiting.  One  other  feature  of  this  stage  often  requires  inter- 
ference— namely,  vomiting. 

If  there  is  much  useless  retching,  a  draught  of  warm  water 
may  help  to  effect  an  evacuation  of  the  stomach;  then  simple  measures 
to  stop  further  vomiting  may  be  pursued,  as  sipping  of  efferves- 
cent drinks  such  as  ginger  ale  or  Seltzer  water  or  putting  a  mus- 
tard paste  on  the  epigastrium.  Bromides  in  10  or  15  grains  (0.66-1 
Gm.)  with  spirits  of  chloroform  in  teaspoonful  doses  may  be  of  value 
given  by  mouth. 

If  the  retching  cannot  otherwise  be  overcome,  administer  mor- 
phine hypodermically,  in  doses  of  gr.  1/12  or  gr.  1/8  (0.005-0.008 
Gm.)  of  the  sulphate. 

Collapse.  In  the  old  and  feeble,  symptoms  of  collapse  may 
threaten  during  the  chill.  These  are  to  be  met  by  hot  drinks 
of  coffee,  brandy  or  whiskey,  or  a  teaspoonful  of  aromatic  spirits  of 
ammonia  in  water;  or  a  little  strong  water  of  ammonia  may  be 
inhaled  from  a  towel  or  handkerchief  held  a  little  way  from  the 
nose. 

This  stage  lasts  from  a  quarter  of  an  hour  in  light  cases  to  two  hours 
in  very  severe  ones;  and  then  come  occasional  flushings  of  heat  and 
gradually  there  is  established  the  febrile  stage. 

Fever.  In  a  few  minutes  the  patient  is  "burning  up  with  fever," 
complaining  as  bitterly  of  the  heat  as  he  was  of  the  cold  shortly  before. 
The  face  is  flushed,  the  whole  skin  red,  the  pulse  bounding. 

The  hot-water  bottles  are  removed,  blanket  after  blanket  comes  off, 
until  only  a  sheet  remains;  bits  of  cracked  ice  are  sucked,  cold 
water  or  cold  lemonade  is  sipped,  cool  sponge  baths  given  or 
sponges  of  water  containing  alcohol.  A  light  rub  with  the  hand,  using 
25  per  cent,  alcohol  in  water,  affords  much  comfort. 

Headache  is  the  feature  of  this  stage  as  vomiting  is  that  of 
the  chill,  though  occurring  also  in  the  first  stage.  This  is  relieved  by 
cold  cloths,  wrung  out  of  ice  water  and  applied  to  the  brow. 
The  cold  sponging  mentioned  lessens  the  intensity  of  the  headache.  If, 
however,  it  is  intense  and  not  lessened  by  the  measures  advised  and, 
especially,  if  delirium  accompanies  it,  one  may  try  codeine  phosphate 
in  1/4  or  1/2  grains  doses  (0.015-0.030  Gm.)  or  the  morphine  sulphate 
in  small  doses  hypodermically,  gr.  1/24  to  gr.  1/12  (0.003-0.005  Gm.) 
may  be  given.  Coal  tars  should  not  be  used. 

This  stage  lasts  usually  from  four  to  six  hours  and  then  as  the  fever 


326  TREATMENT  OF  ACUTE  INFECTIOUS  DISEASES 

declines,  perspiration  appears  on  the  face  and  forehead  and  the  third 
stage  of  sweating  is  ushered  in. 

Sweat.  Soon  the  whole  body  is  covered  with  a  drenching  sweat 
and,  except  "for  the  discomfort  of  the  sweating,  the  patient  grows 
rapidly  better.  Relief  is  afforded  the  patient  in  this  stage  by  rubbing 
the  body  with  dry  towels  and  changing  the  linen.  He  may  be  allowed 
drinks  of  water  or  lemonade  freely. 

If  symptoms  of  collapse  intervene,  as  but  rarely  occurs,  hot  drinks 
and  stimulation  as  advised  during  the  cold  stage  should  be  given. 
Sleep  usually  follows  this  stage. 

Blood  examination  shows  a  moderate  leucocytosis  during  the  attack 
and  leucopenia  with  large  mononuclear  increase  between  the  attacks. 
Parasites  may  be  found  at  any  time  during  the  afebrile  period. 

Such  are  the  events  and  their  treatment  in  the  milder  cases  of  tertian 
and  quartan  fevers  of  this  latitude. 

Of  the  estivo-autumnal  fevers  of  the  North,  it  may  be  said  that  they 
are  more  severe  than  the  other  types,  but  very  rarely  pernicious.  The 
nervous  symptoms  and  the  aching  pains  of  the  limbs  and  back  are 
more  striking  and  the  paroxysm  is  much  longer,  usually  over  twenty- 
four  hours  and  often  permitting  but  a  few  hours  of  intermission  or 
remission. 

The  chills  are  not  as  frank;  the  rise  of  temperature  less  abrupt, 
delirium  or  apathy  more  pronounced  and  the  patient  more  prostrated. 
Parasites  are  found  a  few  hours  after  the  onset  of  the  paroxysm  and 
may  be  very  difficult  or  impossible  to  demonstrate  later.  Such  cases 
often  resemble  typhoid  fever. 

Herpes  labialis  is  common,  especially  in  the  benign  tertian.  The 
spleen  enlarges  and  is  one  of  the  most  pathognomonic  features  of  the 
infection. 

Specific  Treatment.  As  I  have  said  quinine  is  looked  upon 
as  more  truly  a  specific  than  any  other  drug  in  use,  and  yet  its  specificity 
is  due  to  effects  not  confined  to  the  plasmodium  malariae  alone,  but 
common  to  all  protoplasm. 

In  general  it  13  a  protoplasmic  poison.  At  first  and  in  slight  doses, 
this  action  on  protoplasm  is  expressed  by  an  enhancement  of  function, 
that  is,  stimulation;  but  this  in  turn,  in  sufficient  dosage,  is  followed 
by  depression  of  function,  paralysis  of  same  and  death.  That  this  action 
varies  in  degree  in  different  stages  of  cell-growth  and  cell-activity  is 
also  true  and  upon  this  fact  depends  its  usefulness  as  a  drug. 

Now,  the  protoplasm  of  the  malarial  organism  seems  peculiarly 
susceptible  to  it,  but  by  no  means  equally  so  at  all  stages  of  its  develop- 
ment. It  is  so  much  more  susceptible  to  quinine  than  the  body-cells, 


MALARIA  327 

that  amounts  that  will  kill  the  plasmodium  have  no  deleterious  effects 
on  the  latter. 

It  is  during  the  stage  when  development  and  nutrition  are  most  active, 
that  is,  in  the  young  stage  of  the  parasite,  that  quinine  is  most  operative. 
This  fact  has  a  practical  bearing  on  the  administration  of  the  drug. 

Bass  and  Johns  believe  that  the  quinine  does  not  directly  kill  the  para- 
sites but  produces  a  permeability  of  the  red  blood  cells  to  the  blood 
serum  which  contains  an  element  destructive  to  the  plasmodium. 

Time  of  Administration.  Many  rules  are  given  by  numbers 
of  physicians  with  reference  to  the  time  of  administration,  and  by  some 
of  them  with  an  insistence  on  exactness  that  would  seem  to  attribute 
more  of  the  success  to  this  item  in  technique  than  to  the  drug  itself. 
Facts  about  the  absorption  and  excretion  of  quinine  are  as  follows: 
Within  thirty  minutes  evidences  of  it  are  found  in  the  urine.  In  six 
hours  half  of  it  is  eliminated,  but  after  that  the  elimination  is  more  tardy 
and  traces  of  it  can  still  be  found  in  the  urine  after  seventy-two  hours. 

Sporulation — the  setting  free  of  the  young  parasites  in  the  blood- 
stream— occurs  at  the  time  of  the  chill.  We  should  theoretically  get 
the  best  results  by  a  large  dose  given  three  or  four  hours  before  the  antic- 
ipated chill,  at  a  time  when  the  maximum  amount  of  quinine  would  be 
in  the  circulation  to  act  upon  the  organisms  during  their  egress  from 
the  red  blood-cells.  We  may,  then,  a  few  hours  before  the  paroxysm 
give  our  maximum  dose.  It  goes  without  saying  that  this  will  in  no 
way  abort  the  coming  chill,  as  the  organisms  responsible  for  that  are 
protected  in  the  red  blood-cells;  but  it  will  destroy  their  offspring  and 
abort  the  chill  for  which  they  would  be  responsible  forty-eight  or  seventy- 
two  hours  later.  Bethea  is  accustomed  to  give  the  full  day's  dose  at 
this  time,  dividing  it  into  six  parts  and  administering  the  doses  at  one- 
hour  intervals  beginning  five  hours  before  the  anticipated  chill. 

Again,  as  others  advise,  the  quinine  may  be  administered  during 
the  decline  of  the  fever.  The  fever  we  believe  to  be  coincident  with 
the  setting  free  of  the  parasite  in  the  blood.  The  young  organisms 
very  quickly  attach  themselves  to  the  red  cells  which  they  seek  to  pene- 
trate. 

If  quinine  is  given  at  this  time,  its  rapid  absorption,  as  just  expressed, 
brings  it  into  contact  with  them  and  effects  their  destruction. 

Still  others  advise  dividing  the  daily  dose,  administering  a  portion, 
three  times  a  day,  every  four  hours  or  every  six  hours.  As  we  have  seen, 
only  half  the  dose  ingested  is  excreted  in  six  hours,  so  this  procedure 
keeps  the  blood  cinchonized  continuously.  This  method  has  advantages 
where  the  time  of  the  paroxysm  is  more  difficult  to  determine,  as  in  the 
remittent  or  continuous  forms,  in  quotidian  infection  and  in  the  perni- 


328          TREATMENT  OF  ACUTE  INFECTIOUS  DISEASES 

cious  types,  and  particularly  if  there  is  a  constant  migration  of  plas- 
modia  from  cell  to  cell,  as  Mary  Rowley  Lawson  contends. 

So  one  may  administer  the  dose  (1)  a  few  hours  before  an  expected 
paroxysm; "(2)  at  the  decline  of  the  fever  of  a  paroxysm;  or  (3)  divide 
the  dose  throughout  the  twenty-four  hours. 

The  object  is  to  have  enough  quinine  in  the  blood  to  kill  the  organism 
when  it  is  free. 

Preparations.  There  are  numerous  salts  of  this  alkaloid,  repre- 
senting varying  weights  of  the  alkaloid  and  varying  solubility.  Most 
of  the  salts  are  sparingly  soluble;  a  few  freely.  Of  these  the  sul- 
phate which  contains  about  75  per  cent  of  the  alkaloid  (74.31 
per  cent.)  is  the  most  commonly  used  when  the  drug  is  administered 
by  the  mouth.  The  more  soluble  acid  hydrochloride  or  bisulphate,  or 
quinine  and  urea  hydrochloride  is  used  for  hypodermic  purposes. 

The  sulphate  is  practically  insoluble  in  water  (1  in  800),  and  is  usually 
administered  in  capsules  or  wafers.  Pills  and  tablets  are  likely  to  be 
hard  or  tough  and  in  this  way  the  drug  escapes  absorption.  The  2 
grain  (0.15  Gm.)  quinine  capsule  is  the  favorite  unit.  There  is  no  ques- 
tion that  this  drug  were  better  given  in  solution  and,  indeed,  where 
the  condition  of  the  stomach  leads  to  a  suspicion  of  its  impairment  and 
hydrochloric  acid  may  not  be  secreted,  the  solution  should  be  used. 
The  drug  is  freely  soluble  in  any  dilute  acid,  hydrochloric,  sulphuric, 
phosphoric  or  tartaric.  A  minim  per  grain  is  enough.  The  objection 
to  this  method  is  the  intensely  bitter  taste.  Effort  may  be  made  to  dis- 
guise it.  One  way  is  to  dissolve  the  dose  in  a  few  grains  of  citric  acid 
gr.  x  (0.60  Gm.)  in  a  little  lemon  juice,  add  to  it  water  in  which  a  pinch 
of  bicarbonate  of  soda  has  been  dissolved  and  take  while  effervescing. 

The  hydrobromide,  soluble  1:40  or  the  bisulphate,  soluble  in  8  1/2 
parts  of  water  and  the  dihydrochloride  soluble  in  less  than  equal  parts 
of  water  (1  to  0.6),  may  be  used  instead  of  the  sulphate. 

Bethea  favors  the  hydrobromide  because  of  its  ready  solubility,  large 
quinine  content,  and  possible  antidotal  effects  of  the  bromide  to  cin- 
chonism. 

Dosage.  I  am  convinced  that  our  dosage  for  malaria  in  tem- 
perate zones  has  been  too  low  and  accounts  for  the  frequent  relapses. 

Regardless  of  the  form  of  infection  I  advise  gr.  xxx  (2  Gm.)  of  quinine 
a  day  until  the  paroxysms  cease  and  at  least  gr.  xx  (1.30  Gm.)  a  day 
for  ten  days  to  two  weeks,  and  then  gr.  xv  (1  Gm.)  on  two  successive 
days  of  each  week  for  two  months  after.  This  amount  may  be  divided 
into  two  or  three  doses  a  day. 

Bass,  beginning  with  the  same  large  doses,  10  grains  (0.66  Gm.)  three 
times  a  day,  for  three  days,  then  gives  10  grains  for  each  night  for  eight 


MALARIA  329 

weeks  without  intermission.  This  is  the  fruit  of  an  exceptional  clinical 
experience.  Stitt  gives  the  treatment  adopted  in  the  Canal  Zone  where 
tropical  conditions  mean  severe  infections,  as  follows:  15  grains  of 
quinine  three  times  a  day  (45  grains  a  day)  for  a  week  or  until  the  tem- 
perature has  been  normal  five  or  six  days;  then  10  grains  three  times  a 
day  for  ten  or  12  days.  Vedder  recommends  grains  xxx  daily  until  symp- 
toms have  disappeared  and  plasmodia  are  no  longer  found;  then  grains 
xv  daily  for  two  weeks;  then  grains  x  daily  for  two  months  at  least. 

Not  all  tropical  workers,  e.  g.,  Manson  and  Koch,  give  so  large  doses 
as  this.  Moreover,  there  seems  to  be  a  great  variety  of  opinion  about 
the  toxicity  of  the  drug  which  it  is  not  becoming  one  whose  experience 
has  been  confined  to  the  treatment  of  malaria  in  the  temperate  zone  to 
pass  upon.  Using  such  doses  as  I  have  mentioned  in  the  first  para- 
graph under  Dosage,  I  have  never  seen  toxic  results  except  in  rare 
cases  of  idiosyncrasy  that  will  be  discussed  later. 

If  large  doses  are  not  well  borne  by  the  stomach,  the  24  hour  intake 
may  be  divided  into  smaller,  but  more  frequent  doses  and  must  be 
administered  by  night  as  well  as  day  to  keep  the  blood  properly  cin- 
chonized. 

Bethea  favors  more  frequent  administration — he  gives  3  grs.  every 
two  hours  during  the  day  and  every  three  hours  during  the  sleeping 
period.  After  the  period  of  intensive  treatment  he  gives  four  grains 
three  times  a  day  for  about  eight  weeks. 

I  believe  Wellman  is  right  when  he  advises  a  repetition  of  the  treat- 
ment thirty  or  forty  days  after  the  initial  dose.  If  a  case  relapses  it 
means  either  that  the  drug  was  not  absorbed  or  the  dose  was  insuffi- 
cient. It  is  better  with  such  a  relapsing  case  to  use  the  drug  in  solution. 

Quinine  Immunity  or  "  Fastness."  It  should  be  emphatically 
stated  that  perhaps  as  much  or  more  damage  can  be  done  by  too  small 
doses  as  by  very  large  ones:  for  not  only  is  the  "cure"  as  estimated  by 
disappearance  of  symptoms  delayed ;  but  when  small  doses  are  given  at 
the  beginning  of  the  treatment  the  organisms  gain  a  resistance  or  im- 
munity to  quinine  or  as  it  is  sometimes  put,  become  "  quinine  fast"  and 
thus  are  able  to  resist  large  doses  later  and  so  perpetuate  the  initial 
attack  or  prepare  the  way  to  relapses. 

Quinine  in  Children.  Children  require  large  doses  proportion- 
ately; Wellman  gives  one  grain  for  each  year  of  a  child's  age  three  times 
a  day.  This  rule  to  be  followed  to  ten  years. 

Bass  gives  the  following  dosage:  to  infants  under  one  year  1/2  gr. 
(0.03  Gm.) ;  at  one  year  1  grain  (0.06  Gm.) ;  2  years  2  grains  (0.012  Gm.)  ; 
3-4  years  3  grains  (0.2  Gm.) ;  5-7  years  4  grains  (0.25  Gm.)  each  night  in 
5i  (4  c.c.)  of  aromatic  syrup  of  Yerba  Santa.  Older  children  may  take  it 


330  TREATMENT  OF  ACUTE  INFECTIOUS  DISEASES 

in  capsules  as  does  the  adult.  The  doses  are  for  8-10  years  6  grains 
(0.4  Gm.);  11-14  years  8  grains  (0.5  Gm.).  Over  this  age  adult  dose. 
These  doses  are  kept  up  for  eight  weeks. 

Holt  believes  in  much  larger  doses.  He'-feives  an  infant  of  one  year 
8  to  12  grains,  and  says  children  of  five  to  ten  years  require  nearly  as 
much  as  an  adult. 

I  should  favor  the  large  doses.  They  can  be  given  to  infants  and  small 
children  suspended  in  syrup  of  Yerba  Santa,  as  Tannate,  in  chocolate 
lozenges  or  this  prescription  for  a  child  of  6  years: 

.    Quininse  Sulphatis.  „ gr.  xxx          (2  Gm.) 

Ft.  cht.  no.  xviii 

S.  Six  (6)  powders  in  chocolate  syrup  each  day  as  directed. 

Or  it  may  be  given  by  rectum  in  solution  or  in  starch  paste  when 
one  should  use  two  or  three  times  the  dose  by  the  mouth.  Oral  adminis- 
tration is  preferable. 

Pernicious  Infections.  As  I  have  said,  the  pernicious  type  of 
the  disease  is  rarely  seen  in  the  North;  in  the  South  and  in  the  tropics, 
however,  it  is  much  more  common.  It  is  caused  exclusively  by  the 
estivo-autumnal  form  of  the  parasite. 

One  of  the  best  criteria,  aside  from  the  severity  of  the  symptoms, 
for  a  pernicious  infection,  is  that  set  by  some  of  the  tropical  workers; 
namely,  the  percentage  of  infected  cells  and  the  number  of  doubly  in- 
fected cells. 

When  5  per  cent,  of  the  red  cells  are  infected  the  case  trespasses 
upon  the  dangerous. 

The  fever  is  usually  irregularly  remittent  or  constant. 

The  dose  recommended  is  larger  than  those  usually  given  in  temperate 
climes.  While  Rogers  recommends  gr.  x  (0.66  Gm.)  three  times  a  day, 
James  urges  gr.  xlv  (3  Gm.)  a  day,  in  doses  of  gr.  xv  (1  Gm.)  three  times 
a  day  for  at  least  ten  days  and  Wellman  gives  gr.  xx-xxx  (1.30-2  Gm.)  for 
an  initial  dose,  followed  by  gr.  x-xx  (0.60-1.30  Gm.)  every  four  hours, 
until  the  attack  clears  up  (one  to  four  days),  then  about  gr.  xx  a  day. 

The  profound  intoxications  are  seen  more  commonly  in  those  who 
have  had  repeated  attacks  or  in  neglected  cases,  and  in  those  in  whom 
resistance  has  been  lowered  from  one  cause  or  another. 

Profound  depression  of  all  the  vital  centres  is  seen,  and  a  particular 
imposition  of  the  poison  on  one  or  the  other  organ  gives  a  stamp  to  the 
picture  and  affords  abundant  cause  for  error  in  diagnosis. 

Thus  we  have  a  comatose  form  in  which  sudden  loss  of  consciousness 
resembles  apoplexy;  apathetic  conditions  with  icterus,  like  yellow  fever; 
diarrheas  that  resemble  cholera  or  dysentery;  and  not  infrequently  an 


MALARIA  331 

attack  characterized  by  profound  prostration,  collapse,  excessive  sweat- 
ing, sometimes  subnormal  temperature,  the  algid  form. 

In  these  cases  quinine  must  be  used  hypodermically  or  intravenously 
according  to  the  urgency. 

Hypodermic  Use.  Of  the  two  methods,  subcutaneous  and  intra- 
muscular, the  choice  should  be  decidedly  for  the  latter.  The  rate  of 
absorption  is  more  rapid  and  the  danger  of  necrosis  less.  There  is  now 
an  almost  universal  condemnation  of  the  subcutaneous  route. 

The  best  salt  for  hypodermic  use  is  the  dihydrochloride,  which  dis- 
solves in  less  than  its  own  weight  in  water.  Make  up  a  solution  as 
follows : 

Quinine  dihydrochloride 5.0         Gm. 

Distilled  sterile  water 10 . 0          c.c. 

One  may  take  m.  xv  (1  c.c.)  of  the  solution  given  above  and  dilute  to 
Siiss.  (10  c.c.);  better  5ss.  (15  c.c.)  or  better  yet  5i  (30  c.c.)  and 
slowly  inject  under  the  skin  where  the  subcutaneous  tissue  is  loose  or 
into  the  muscle. 

The  amount  needed  in  the  twenty-four  hours  is  some  24  grains,  given 
in  divided  doses  in  this  way.  In  worst  cases  up  to  gr.  xlv  (3  Gm.). 

In  these  severe  but  less  urgent  forms,  if  given  by  the  mouth,  the 
amount  should  run  up  to  the  full  doses  of  Wellman  given  above. 

This  method,  necessary  in  this  class  of  cases  is  not  free  from  disa- 
greeable results  and  in  exceptional  circumstances  real  danger. 

As  commonly  used,  the  solutions  are  too  concentrated,  the  result 
being  that  a  precipitate  from  the  serum  is  caused  by  the  quinine  and  the 
tissues  may  undergo  necrosis. 

The  more  dilute  the  solution  the  safer  the  procedure  becomes; 
it  should  never  be  more  than  10  per  cent.  Moreover,  too  concentrated 
solutions  will  not  be  absorbed. 

One  should  take  every  precaution  to  be  assured  of  a  sterile  needle, 
syringe  and  skin,  should  paint  the  latter  with  iodine  and  inject  into  the 
gluteal  region  or  muscles  of  the  back  and  go  down  deep  into  the  muscle. 
There  is  likely  to  be  some  pain  and  induration  but  this  probability  is 
greatly  lessened  by  the  high  dilutions. 

However,  abscesses  not  infrequently  occur  in  spite  of  all  pre- 
cautions. 

Another  preparation  of  quinine  which  is  excellent  for  hypodermic  use 
and  freely  soluble  is  the  quinine  and  urea  hydrochloride  to  be  used  in 
the  same  dose. 

Hypodermoclysis.  The  same  preparation  in  a  gr.  xv  (1  Gm.) 
dose  is  used  in  2  to  3  pints  (1,000-1,500  c.c.)  of  salt  solution  (5i-0i 


332  TREATMENT  OF  ACUTE  INFECTIOUS  DISEASES 

(4  Gm.-500  c.c.).  In  diarrheal  forms  and  in  collapse  this  should  be  an 
especially  valuable  method. 

Intravenous  Use.  In  severe  forms  of  pernicious  malaria,  by 
far  the  best  practice  is  to  put  the  drug  into  ttte  vein.  This  may  be  done 
in  physiological  salt  solution.  For  example: 

Quinine  Hydrochloride 0.50  Gm.          (gr.  viiss.) 

Sodium  Chloride 0 . 25  Gm.          (gr.  iii.) 

Sterilized,  distilled  water 30.00  c.c.          (gi.) 

or  twice  this  dilution.  In  most  urgent  cases  two  and  four  times  the 
dose  gr.  xv-xxx  (1-2  Gm.). 

Bass  thinks  a  10  grain  dose  is  sufficient  and  much  larger  doses  dan- 
gerous. His  method  of  dropping  two  5-grain  tablets  of  quinine  dihy- 
drochloride  into  the  barrel  of  a  20  c.c.  syringe,  drawing  up  physiological 
salt  solution  to  dissolve  them  and  then  filling  to  20  c.c.  and  injecting,  is 
simple  and  convenient.  Others  use  a  salvarsan  apparatus  for  the  pur- 
pose. 

There  seems  to  be  much  controversy  among  authorities  as  to  proper 
dilutions;  some  urging  the  value  and  safety  of  10  per  cent,  solutions, 
others  pleading  for  high  dilutions  1  to  250;  critics  find  danger  in  one  or 
the  other. 

Dilutions  of  1  to  30  to  1  to  60  seem  fairly  free  from  objections.1 

The  dose  should  be  repeated  at  intervals  of  a  few  hours,  2  or  3  up  to  6, 
until  the  patient  is  so  far  improved  as  to  make  oral  administrations 
effectual.  This  usually  occurs  in  24  hours.  The  necessity  for  frequent 
intravenous  dosage  is  emphasized  by  the  rapid  elimination  of  quinine  so 
administered,  it  being  only  a  matter  of  a  few  hours. 

Inject  all  at  once  into  the  basillic  vein  made  prominent  by  a  ligature 
as  above.  (For  technique  see  Rheumatism,  Chap.  IX.) 

Other  veins  if  more  accessible  may  be  chosen. 

A  word  more  about  quinine  before  we  proceed  with  our  subject.  This 
drug  is  an  antipyretic  and  used  as  such  under  certain  circumstances. 
Its  antipyretic  action  is  apparently  due  to  the  depression  of  function  of 
protoplasm,  of  which  mention  has  been  made.  Some  effect,  too,  upon 
ferment  action  can  be  determined.  The  result  is  a  lessened  output  of 
heat  from  the  tissues,  through  direct  action  and  not  through  the  inter- 
mediation of  the  heat  regulating  nervous  mechanism.  It  must  be  re- 
membered, however,  that  in  malaria  the  control  of  temperature  is  to  be 
attributed  entirely  to  the  destruction  of  the  plasmodium  and  not  at  all  to 
this  pharmacological  action. 

1  Some  of  the  pharmaceutical  houses  now  put  up  in  ampoules  quinine  in  solu- 
tion ready  for  immediate  use. 


MALARIA  333 

Cinchonism.  Of  more  importance  to  us  are  those  toxic  symp- 
toms that  may  occur  when  inordinate  doses  of  the  drug  are  given,  and  so 
can  be  avoided ;  and  which  occur  after  very  small  doses  in  certain  people, 
whose  reaction  to  the  drug  constitutes  an  abnormality  which  we  call  an 
idiosyncrasy,  and  cannot  be  avoided.  Idiosyncrasy  is  one  of  those 
philological  accomplishments,  sent  as  an  advance  agent  to  occupy  a 
territory  until  knowledge  shall  advance.  It  is  the  shadow  rather  than 
the  substance  of  a  thing,  but  like  many  other  shadows  in  affairs  temporal 
it  is  allowed  to  usurp  and  continue  to  rule  as  the  real  thing.  It  is  derived 
from  two  Greek  words,  ttw,  own,  and  <rvypa(7is}  mixture, — having  its 
own  mixture,  that  is  a  quality  peculiar  to  the  individual.  What  that 
quality  is  and  how  it  operates  is  left  for  the  future  to  elucidate. 

Since  we  have  become  more  familiar  with  the  phenomena  of  ana- 
phylaxis,  attempts  have  been  made  to  find  analogies  in  drug  idiosyn- 
crasies. They  fail  so  far  that  they  tempt  us  to  apply  another  term  to  the 
phenomena,  allergic;  but  succeed  to  the  extent  of  furnishing  us  with  a 
method  of  detecting  sensitization  and  in  some  measure  of  effecting 
desensitization. 

These  toxic  symptoms  are  called  "cinchonism." 

The  earliest  and  most  common  are  ringing  or  roaring  in  the 
ears  and  a  mild  degree  of  deafness.  If  it  amounts  to  no  more 
than  this  we  give  it  no  consideration,  but  this  may  go  on  to  complete 
deafness. 

This  has  been  attributed  to  congestion  and  hemorrhages  in  the 
tympanum,  but  Cushny  believes,  in  the  light  of  recent  research,  that 
this  view  is  not  correct,  but  that  the  phenomena  are  attributable  to 
degenerative  changes  occurring  in  the  spiral  ganglion  in  the  cochlea. 

Less  frequently  than  the  hearing,  the  vision  is  affected.  The  pu- 
pils do  not  react  to  light,  the  field  of  vision  is  contracted,  the  color  vision 
disturbed,  and  blindness  may  ensue. 

The  visible  changes  in  the  eye  are  contraction  and  even  obliteration 
of  the  retinal  vessels,  pallor  of  the  optic  disc,  sometimes  degenerative 
changes  in  the  retinal  nerve-cells,  and  even  atrophy  of  the  optic  nerve. 

If,  as  sometimes  happens,  the  disturbance  of  vision  is  due  to  plugging 
of  the  retinal  vessels  by  the  plasmodia  the  pupils  do  react  to  light  and 
the  disc  is  a  greyish  led. 

Skin  eruptions  occur  in  great  variety.  The  most  common  is 
an  erythema  that  has  been  mistaken  for  scarlatina,  an  illusion 
heightened  by  the  fact  that  it  may  desquamate;  next  to  that,  urti- 
caria! wheals.  Hemorrhagic  rashes  also  occur,  which  on  occasion 
may  give  rise  to  the  diagnosis  of  a  septic  process.  Less  commonly,  the 
drug  may  cause  gastric  discomfort  of  a  marked  degree  and  is 


334  TREATMENT  OF  ACUTE  INFECTIOUS  DISEASES 

believed  at  times  to  cause  hemorrhage  from  the  kidneys.  In  a 
case  of  malaria  this  may  give  rise  to  the  diagnosis  of  black  water  fever 
and,  indeed,  Koch  maintains  that  black  water  fever  is  due  to  quinine. 

Contraindications  to  Quinine.  Whea  idiosyncrasies  do  exist 
to  a  marked  degree  they  constitute  contraindications  to  the  use  of  the 
drug. 

Further  contraindications  are  any  inflammatory  process  in  the  middle 
ear  or  labyrinth,  amblyopia  and  amaurosis. 

Pregnancy  is  said  to  contraindicate  the  use  of  quinine  because  of  its 
effect  on  uterine  muscle  substance,  but  the  best  opinion  voices  dissent  to 
this  statement  and  the  greater  danger  of  abortion  and  miscarriage  from 
the  untreated  malaria.  If  one  feels  in  doubt  about  the  effect  of  quinine 
in  pregnancy,  bromides  and  opium  may  be  combined  with  the  quinine 
in  treatment. 

Other  Forms  of  Quinine.  Beside  the  salts  already  described 
mention  should  be  made  of  cinchona  bark;  for  example,  Warburgh's 
tincture.  Many  have  thought  that  they  got  results  from  Warburgh's 
tincture  that  they  could  not  get  from  quinine.  It  must  be  believed  that 
this  experience  is  due  to  inefficient  dosage  and  usage  of  the  salts  of  the 
alkaloid  quinine.  Other  alkaloids  of  cinchona  are  not  more  efficient. 

Euquinine  or  ethylcarbonate  of  quinine,  contains  81  per  cent, 
of  quinine,  is  almost  insoluble  in  water,  so  almost  tasteless.  Quinine 
tannate  contains  30  per  cent,  of  quinine.  Hence  the  dose  should  be  2  1/2 
times  as  much  as  the  latter.  It  is  insoluble  and  can  be  taken  by  children. 

Idiosyncrasies.  These  are  expressed  in  individuals,  after  ingestion 
of  small  doses  of  quinine  by  the  symptoms  detailed  under  cinchonism 
and  usually  by  an  intensification  of  these  symptoms.  O'Malley  and 
Richey  in  a  case  of  quinine  idiosyncrasy  provoked  a  cutaneous  reaction 
by  applying  solutions  of  quinine  salts  1-10  to  an  abrasion  just  going 
through  the  skin,  on  the  flexor  surface  of  the  fore-arm,  using,  of 
course,  a  control;  this  is  the  common  method  of  determining  sensiti- 
zation  to  pollens  and  proteins.  The  reaction  was  an  area  of  edema, 
accompanied  by  itching  and  burning,  surrounded  by  a  halo  of  erythema, 
3-5  cm.  in  diameter. 

Desensitization  was  effected  by  giving  0.005  Gm.  of  a  quinine 
salt  with  0.5  Gm.  of  bicarbonate  of  soda.  In  one  hour  and  a  half  0.1  Gm. 
of  the  quinine  with  0.5  Gm.  of  sodium  bicarbonate  was  given. 

Each  day  the  desensitizing  doses  of  0.005  Gm.  as  given  above  was 
administered,  but  the  second  dose  given  one  and  a  half  hour  later  was 
increased  by  0.1  Gm.  and  the  same  amount  (0.5  Gm.)  of  sodium  bicar- 
bonate. Only  one  dose  a  day  is  given.  In  this  way  it  may  be  possible 
to  work  the  dose  up  to  one  or  two  grams.  Modifications  of  this  method 


MALARIA  335 

are  successful,  all  being  a  gradually  increasing  dose,  beginning  with  a 
very  small  one. 

SYMPTOMATIC  TREATMENT  OF  PERNICIOUS  MALARIA 

The  Cerebro-Spinal  Types.  This  includes  the  delirious  and 
comatose,  the  hyperpyretic,  the  irritative,  and  paralytic  suggesting 
general  or  focal  brain  disturbance. 

The  Comatose  Form.  This  usually  follows  on  delirium  and  cases 
in  which  headache  and  restlessness  have  been  marked  or  may  come 
on  so  abruptly  that,  like  a  case  of  Bass',  picked  up  in  the  street,  may  be 
mistaken  for  drunkenness.  A  chill  may  or  may  not  precede  the  onset. 
The  pulse  is  rapid  and  thready,  the  heart  sounds  poor  and  collapse 
not  uncommonly  ensues.  The  organism  found  is  the  estivo-autumnal, 
but  in  one  of  Pepper's  cases  was  the  plasmodium  vivax.  Such  attacks 
are  believed  to  be  due  to  the  plugging  of  the  cerebral  capillaries  by  the 
plasmodia,  owing  to  the  size  and  shape  of  the  Schizontes  or  the  agglu- 
tination processes.  Intravenous  quinine  therapy  is  indicated  as  de- 
scribed above,  beginning  with  a  10-grain  dose. 

Irritative  and  Paralytic  Forms.  The  irritative  and  paralytic  forms 
are  rife  with  diagnostic  errors,  giving  rise  to  general  convulsions,  epilepti- 
form  convulsions,  hemiplegia,  aphasia,  tetanic  seizures,  cerebellar  and 
bulbar  manifestations.  The  difficulty  in  these  cases  lies  in  establishing  a 
diagnosis.  Of  course  with  the  previous  history  of  malaria,  tropical  resi- 
dence, or  the  findings  of  a  routine  blood  examination  these  difficulties  dis- 
appear, but  one  appreciates  how  often  these  material,  aids  are  wanting. 
When  the  diagnosis  is  made  the  treatment  is  intravenous  medication 
and  the  treatment  of  collapse  as  described. 

Collapse.  For  collapse,  stimulation  with  strophanthin  }/%  mg.  into  the 
vein,  strychnine  sulphate  gr.  1/30(0.002  Gm.),  or  caffeine,  sodium 
salicylate,  or  benzoate  gr.  v  (0.33  Gm.)  is  required,  and  in  the  more 
urgent  cases  more  rapidly  acting  agents  should  be  used,  such  as  camphor 
in  10  per  cent,  solution  in  olive  or  sesame  oil  or  ether  gr.  iii  (0.2  Gm.), 
epinephrin  (adrenalin)  1  to  1,000,  m.  xv  (1  c.c.)  or  ammonia  inhala- 
tions. Drugs  should  be  given  into  a  vein  or  into  a  muscle. 

Hyperpyrexia.  The  symptoms  are  those  of  heat  stroke  and  the 
temperature  may  rise  to  110°  F.  These  patients  pass  into  coma  and 
the  condition  is  usually  a  fatal  one.  It  is  best  controlled  by  cold  baths, 
at  65°  F.  or  beginning  higher  at  85°  F.  to  90°  F.,  and  cooling  to  65°  F., 
sponging  the  head  meanwhile.  This  is  continued  until  the  temperature 
is  reduced  below  the  danger  point. 

For  extreme  nervousness  morphine  sulphate  is  the  best,  because  the 
least  depressing  and  most  effectual  of  the  sedatives.  . 


336  TREATMENT  OF  ACUTE  INFECTIOUS  DISEASES 

Algid  Forms  are  characterized  by  pallor,  cold,  clammy  skin, 
small  pulse  and  signs  of  collapse.  Diarrhea  of  a  profuse  type  with  or 
without  vomiting  and  cramps  in  the  legs  simulate  cholera;  in  others 
the  stools  contain  blood  and  mucus  and  are  termed  the  dysenteric  type; 
others  in  which  profuse  hemorrhages  occur  are  called  the  hemvr- 
rhagic  type  and  if  great  sweating  with  collapse  is  a  feature  are 
called  the  diaphoretic  type. 

Stitt  says  cases  may  even  simulate  an  acute  hemorrhagic  pancreatitis. 

In  all  these  intravenous  quinine  therapy  is  indicated  as  described  above 
and  with  the  treatment  of  the  collapse  as  detailed  under  that  section. 

In  the  algid  form  the  body  heat  must  be  maintained  by  hot  drinks 
containing  coffee,  brandy,  or  whiskey;  by  blankets  and  hot  bottles  or 
bricks  about  the  body  and  the  hot-water  bag  at  the  feet;  and  by  hot 
rectal  injections  containing  coffee. 

Choleraic  Form.  In  the  choleraic  form  the  same  line  of  treat- 
ment with  hypodermoclysis  or  venous  infusion  of  warm  salt  solution 
is  indicated. 

Morphine  is  to  be  injected  to  control  the  peristalsis. 

Bilious  Remittent  Fever.  This  form  is  characterized  by  severe 
vomiting,  the  vomitus  containing  bile,  the  stools  and  urine  charged 
with  bile  and  jaundice  appearing  as  early  as  the  second  day;  this  form 
is  serious,  both  because  of  the  fatalities  accompanying  it  and  because 
of  the  cachexia  following  upon  it. 

The  treatment  is  urgent  and  must  be  administered  intravenously; 
the  vomiting  is  incompatible  with  oral  administration. 

Multiple  infections  may  occur  with  any  of  the  plasmodia,  but 
seems  to  be  more  frequent  with  the  estivo-autumnal.  Of  course  this 
intensifies  the  infection,  makes  for  greater  destruction  of  red  cells; 
hence  anemia,  and  blurs  the  picture. 

The  treatment  is  the  same  as  in  a  simple  infection  unless  its  severity 
counsels  intravenous  medication. 

Kidney  Complications  occur.  Albuminuria  is  frequent  during 
the  attacks,  in  some  30  per  cent,  of  the  tertian  and  quartan,  and  50  per 
cent,  of  the  estivo-autumnal.  This  must  not  be  taken  too  seriously, 
as  real  nephritis  rarely  ensues  in  the  milder  forms  of  the  disease.  Tak- 
ing the  estivo-autumnal  form  and  the  severe  infections  it  induces  in  the 
tropics,  nephritis,  as  a  sequel,  will  amount  to  nearly  3  per  cent,  and  is 
usually  of  the  chronic  parenchymatous  variety. 

These  conditions  are  to  be  treated  in  the  same  way  as  if  arising  from 
any  other  cause. 

Large  liver  and  large  spleen  may  persist  without  symptoms  of  any 
kind  attributable,  to  any  interference  with  their  functions. 


MALARIA  337 

Heart.  In  some  cases  of  pernicious  malaria,  dilatation  of  the 
heart  has  occurred.  This  indicates  prompt  stimulation  by  the  digitalis 
group,  preferably  strophanthin  by  the  vein,  1  /2  mg. 

Lungs.  Bronchitis  of  a  mild  type  is  not  uncommon,  but  more 
rare  and  curious  is  the  condition  with  the  signs  of  a  broncho-pneumonia 
periodically  occurring  and  yielding  to  quinine. 

Anemia.  The  marked  degree  of  anemia  accompanying  malaria 
has  never  been  satisfactorily  explained,  as  the  destruction  of  cells  has 
been  out  of  all  proportion  to  the  number  of  parasites  seen. 

Obviously  there  was  another  factor  operative  upon  uninfected  red 
cells  that  made  them  share  in  the  destruction,  some  hemorrhagic  dis- 
solving substance  as  Manson  put  it  or  a  toxin  from  the  plasmodium 
acting  on  uninfected  cells  as  Ewing  conjectured.  Very  recently  two 
theories  have  been  advanced,  one  by  Wade  Brown  who  on  the  basis  of 
experimentation  attributes  the  phenomena  or  believes  them  influenced 
by  the  hematin  set  free  from  the  infected  cells;  and  that  of  Mary  Rowley 
Lawson,  who  has  observed  the  constant  migration  of  the  plasmodium, 
from  cell  to  cell,  resulting  in  their  destruction.  This  migration  is  seen 
in  parasites  of  all  ages. 

Now  and  then  the  anemia  is  most  intense  and  simulates  pernicious 
anemia.  Pepper  reports  one  such  case  and  I  recall  a  very  striking  ex- 
ample with  extensive  retinal  hemorrhages  in  my  own  service  at  Bellevue 
Hospital. 

After  the  tertian  and  quartan  infections,  repair  of  the  blood  is  rapid; 
after  the  estivo-autumnal  form  less  so. 

Good  food,  air,  changes  of  surroundings,  iron  and  arsenic  all 
help  recovery. 

Sequelae.  After  the  severe  infections  there  are  certain  sequelae 
that  are  possibilities  that  must  be  taken  into  consideration. 

The  first  of  these  are  the  mental  disturbances,  delusional  in- 
sanity, mania  and  most  common  of  all  melancholia. 

Sharp  watch  must  be  kept  of  these  exhausted  subjects  to  appreciate 
any  mental  aberration,  any  depression  presaging  melancholia,  with 
its  self-destructive  impulses. 

RELAPSES 

The  relapse  is  more  to  be  dreaded  than  the  initial  attack.  It  is  more 
fatal,  it  is  more  persistent  and  less  amenable  to  treatment  and  it  finds 
the  patient  reduced  and  less  able  to  resist.  Undue  exposures  to  wet 
and  cold,  fatigue,  and  the  occurrence  of  other  diseases  invite  a  relapse, 
but  one  great  factor  responsible  for  relapses  is,  as  James  has  emphasized, 
an  insufficient  quinine  treatment  of  the  initial  attack. 


338  TREATMENT  OF  ACUTE  INFECTIOUS  DISEASES 

He  believes  that  the  relapse  is  due  to  a  renewal  of  the  vitality  of  the 
asexual  cycle,  which  is  endowed  with  a  large  "potential  of  vitality" 
and  that  the  asexual  cycle  can  become  relatively  immune  to  the  protec- 
tive forces  of  the  body  and  also  to  quinine;  that  is,  can  become  " quinine- 
fast." 

Others  believe  that  the  relapse  is  simply  due  to  increased  numbers 
of  the  asexual  organisms  which  have  been  persistent  since  the  previous 
attack,  but  in  numbers  insufficient  to  give  rise  to  symptoms. 

Relapses  may  occur  (without  reinfection)  even  after  years,  but  are 
less  likely  to  occur  after  the  malignant  tertian;  nor  do  such  long  intervals 
intervene  between  the  attacks  and  relapses  in  this  infection  as  in  the 
others. 

During  a  relapse  the  large  dose  by  the  vein  as  above  is  indicated  and 
a  plea  is  made  for  larger  doses  in  all  forms  of  the  initial  infection. 

Latent  Malaria  is  a  term  applied  to  the  continued  infection 
which  leads  to  relapses,  often  provoked  by  exposures,  change  of  climate, 
excesses,  surgical  operation  and  parturition. 

Masked  Malaria  is  a  term  applied  to  certain  symptoms,  not 
a  part  of  the  usual  picture,  such  as  neuralgias,  headaches,  gastro-intes- 
tinal  trouble,  recurring  periodically  which  seem  to  disappear  on  quinine 
medication. 

Malarial  Cachexia.  There  are,  however,  cases  in  which  re- 
peated attacks  have  occurred,  where  the  treatment  has  been  neglected 
or  been  insufficient,  where  a  chronic  poisoning  is  set  up  that  is  termed 
malarial  cachexia.  These  patients  show  but  few  organisms  in  the  blood, 
and  these  more  commonly  during  the  slight  febrile  period  that  interrupt 
long  intervals  of  normal  or  subnormal  temperature.  These  are  usually 
the  estivo-autumnal  form,  and  are  not  easy  of  demonstration.  The 
patients  are  markedly  anemic,  with  the  type  of  secondary  anemia;  the 
face  often  shows  a  dirty  earth-colored  pigmentation.  They  are  ema- 
ciated, nervous,  depressed,  and  constantly  fatigued  physically  and 
mentally  inefficient,  have  a  poor  appetite  and  readily  get  short  of  breath. 

Next  to  the  anemia  the  enormous  size  of  the  spleen  is  the  most  notable 
clinical  manifestation.  It  is  easily  ruptured  or  its  pedicle  may  become 
twisted. 

These  cases  should  be  removed  from  the  malarious  district  in 
which  they  reside,  to  one  free  from  infection :  to  the  mountains  or  to  a 
suitable  seashore  resort.  If  this  cannot  be  done,  attempts  must  be  made 
to  protect  the  patient  from  further  infection,  that  is,  bites  of  mos- 
quitoes, by  choosing  an  upper  room,  and  taking  special  care  to  avoid 
exposure  toward  nightfall. 

Quinine  should  be  begun  at  once.    It  has  been  the  custom  to  give  such 


MALARIA  339 

doses  as  quinine  gr.  iv  three  times  a  day,  or  in  more  severe  cases  up 
to  gr.  xvi  or  gr.  xx  a  day  until  the  slight  afternoon  rise  of  temperature 
that  usually  accompanies  the  infection  subsides.  Then  the  dose  of  gr.  iv 
three  times  a  day  is  cut  down  to  gr.  iii  and  gr.  ii  three  times  a  day  and 
continued  in  these  doses  for  weeks. 

I  think  these  doses  are  insufficient,  for  the  cachexia  usually  means  an 
insufficient  quinine  administration  in  the  initial  attack  and  the  persis- 
tence of  the  malarial  organism  in  a  form  peculiarly  resistant  to  quinine. 

Quinine  doses  should  be  as  rigorous,  then,  as  in  a  well-treated  initial 
attack  and  if  this  does  not  answer  the  use  of  the  drug  hypodermically  or 
intravenously  in  doses  of  gr.  xx  (1.30  Gm.)  a  day  is  indicated. 

But  after  all  the  prophylactic  treatment  by  a  sufficiency  of  quinine 
in  the  initial  attack  is  what  should  be  emphasized;  together  with  a 
repetition  of  the  treatment  in  30  or  40  days  after  the  initial  attack  as 
advised  by  Wellman,  or  15  grains  a  day  for  two  successive  days  each  week 
for  two  or  three  months  as  advised  by  Deaderick. 

Iron  and  arsenic  are  of  great  help  in  these  cases  to  improve  the 
blood  state. 

Iron.  Iron  may  be  given  in  the  form  of  a  carbonate  of  iron  or  other 
iron  preparation.  I  prefer  the  carbonate,  e.  g.,  pilula  ferri  carbonatis 
(Blaud's)  gr.  v  (0.30  Gm.)  one,  three  times  a  day. 

Arsenic.  Arsenic  may  be  given  as  Fowler's  solution,  liquor  potassi 
arsenitis,  m.  iii  (0.20  c.c.),  increasing  m.  i  (0.075  c.c.)  each  day  up  to  m. 
viii  or  x  (0.50-0.75  c.c.)  three  times  a  day  or  to  the  point  of  some  mani- 
festation of  intolerance,  as  suffusion  of  the  eyes  or  gastric  disturbance. 

Iron  and  arsenic  may  be  combined  in  pill  form,  e.  g. : 

9 

Arseni  Trioxidi gr.  ^  (0.045) 

Mass.  Ferri  Carb., gr.  cl          (10.00) 

M.  ft.  cap.  no.  xxx. 

S.    One  after  each  meal. 

This  gives  us  gr.  v  (0.30  Gm.)  of  the  mass  of  carbonate  of  iron  and 
gr.  1  40  (0.0015  Gm.)  of  the  arsenious  acid  at  a  dose. 

Another  excellent  arsenic  compound  is  the  cacodylate  of  soda  in  doses 
of  gr.  ss.  to  gr.  iii  a  day  for  7-14  days  which  may  be  repeated  after  an 
interval  if  needed.  This  is  best  administered  hypodermically.  Most 
pharmaceutical  houses  furnish  the  drug  in  ampoules  in  solutions  ready 
for  hypodermic  use. 

The  nervous  manifestations  may  be  helped  by  strychnine  in 
doses  of  gr.  1/40  (0.0015  Gm.)  to  gr.  1/30  (0.0020  Gm.)  three  times  a 
day,  taken  with  the  iron  and  arsenic;  and,  indeed,  they  may  all  be 


340  TREATMENT  OF  ACUTE  INFECTIOUS  DISEASES 

incorporated  in  one  pill  or  capsule.    One  should  always  know  that  the 
pills  ordered  are  fresh. 

Plenty  of  fresh  air  and  sunshine  are  even  more  important  than 
drugs.  Good  food  and  plenty  of  it  to.,  make  good  the  extensive 
tissue  destruction;  cool  baths,  showers,  light  massage  and  exer- 
cise; at  first  by  walking,  later,  as  the  patient's  strength  returns,  by 
golfing  and  horse-back  riding,  and  at  the  shore  by  swimming  complete 
the  treatment. 

If  the  spleen  is  much  enlarged,  care  must  be  taken  that  neither  exer- 
cise nor  occupation  shall  be  of  such  a  violent  nature  as  to  threaten  its 
rupture. 

Substitutes  for  Quinine.  What  is  to  be  done  if  the  patient 
cannot  take  quinine? 

I  hesitate  to  offer  any  substitute  because  there  is  no  other  that  is 
even  remotely  comparable  to  quinine  and  the  "cannot"  is  often  a 
prejudice  on  the  part  of  the  patient,  or  a  result  of  ignorant  usage,  as 
colossal  dosage,  insoluble  pills,  and  nauseous  mixture.  Again  the  little 
disturbances  of  hearing  are  interpreted  too  seriously  and  further  effort 
to  continue  the  drug  is  given  up.  Idiosyncrasies  of  serious  import  are 
very  rare,  and  even  these  may  be  dealt  with  as  detailed  above. 

It  is  a  detriment  both  to  the  physician  and  patient  to  convey  the 
idea  that  anything  else  is  nearly  as  good,  or  is  a  fair  substitute. 

Methylene-blue  has  been  advocated  as  such.  It  is  a  very  poor  sub- 
stitute. If,  however,  we  are  actually  debarred  from  using  quinine,  then 
we  may  try  it  in  doses  of  gr.  viiss.  to  gr.  xv  (0.5-1  Gm.)  a  day,  divided 
into  three  or  four  portions. 

One  should  remember  to  warn  the  patient  that  the  drug  will  lend  color 
to  the  urine,  a  rather  startling  phenomenon  to  a  patient  who  is  not 
informed,  and  that  strangury  or  diarrhea,  intervening  in  the  course  of 
treatment,  may  be  due  to  the  drug. 

Arsenic,  both  inorganic,  as  Fowler's  Solution  or  the  oxide  and  organic 
as  atoxyl  and  soamin  have  been  used,  but  with  no  very  encouraging 
results.  Salvarsan  is  the  most  efficient  arsenical  preparation  when 
quinine  fails  or  may  not  be  used.  It  is  given  as  when  used  for  syphilis  at 
weekly  intervals.  X-ray  or  radium  treatment  of  the  spleen  is  said  to  act 
as  an  adjuvant  to  quinine. 

Convalescence.  Change  of  air  and  especially  a  removal  from 
a  malarious  district;  open  air  and  increase  in  the  diet,  with  such 
drugs  for  the  anemia  and  such  tonics  as  were  named  under  Cachexia 
with  a  repetition  of  the  quinine  series  as  mentioned  above  are  the  con- 
siderations to  be  borne  in  mind  during  convalescence. 
Prophylaxis.  We  are  so  well  informed  now  as  to  the  sequence 


MALARIA  341 

of  events  in  malarial  infection,  as  to  the  role  of  the  mosquito,  the  indi- 
vidual and  the  malarial  organism,  that  our  prophylaxis  is  clearly  de- 
fined in  measures  aimed  at  the  three  links  in  this  chain. 

Destruction  of  the  Mosquito.  The  mosquito  like  Carthage 
"delenda  est"  and  medical  Catos  have  arisen  to  reiterate  the  slogan. 

Mosquitoes  breed  in  marshes,  ponds,  pools  or  any  receptacle  of  quiet 
water,  even  cisterns,  buckets  or  tin-cans. 

Where  municipalities  have  become  sufficiently  interested  or  in  cer- 
tain territories  under  control  of  the  Federal  government,  vast  stretches 
of  marshes  have  been  drained  for  the  extermination  of  the  mos- 
quito or,  in  smaller  areas,  water-containing  depressions  have  been 
filled  in. 

Where  communities  are  ignorant  and  careless,  brigades  of  mosquito 
exterminators  have  been  formed,  whose  business  it  is  to  see  that  cisterns 
and  water  receptacles  are  screened,  that  small  pools  are  filled, 
rubbish  containing  water  disposed  of  or  a  thin  layer  of  crude 
petroleum  poured  on  the  surface. 

Crude  petroleum  is  the  most  effectual  substance  used  to  exter- 
minate the  mosquito  over  extensive  surfaces  of  water.  The  larvae  of  the 
mosquito  have  to  come  to  the  surface  of  the  water  to  breathe.  The  oil 
prevents  their  access  to  the  air  and  fills  their  air-channels. 

One  should  use  about  1/2  pint  to  every  100  square  feet  of  surface  and 
this  should  be  repeated  at  two  weeks'  intervals.  Crude  carbolic  acid 
has  been  recommended. 

Small  fish  and  tad  poles  and  certain  water  insects  all  feed  on  the  pests. 

Grass  and  small  bushes  harbor  mosquitoes,  these  should  be  cut  about 
dwellings. 

Numerous  odorous  substances  have  been  used  to  kill  the  mosquito 
in  a  closed  space,  the  best  of  these  is  pyrethrum  or  pellitory,  which 
contains  an  acrid  resinous-like  substance,  which  when  the  powder  is 
burned,  gives  fumes  that  stupefy  them. 

Protection  of  the  Individual.  Education  in  schools,  public  lec- 
tures, disseminated  literature,  explaining  to  individuals  how  proper 
methods  may  be  used  in  their  own  environment,  is  one  of  the  prophy- 
lactic measures  of  the  highest  import,  for  through  this  means  both 
personal  and  civic  responsibility  is  cultivated. 

Swatting  with  a  fly  swatter  is  certainly  remunerative  exercise  in 
mosquito  infested  rooms. 

Pyrethrum  powder  in  a  little  alcohol,  two  pounds  per  1,000  cubic  feet 
may  be  burned  in  a  room  closed  for  four  hours;  this  stupifies  the  mos- 
quitoes, which  are  then  swept  up  and  burned.  (Stitt.) 

Sulphur  is  more  certain  in  its  effects  when  burnt  in  the  proportion 


342  TREATMENT  OF  ACUTE  INFECTIOUS  DISEASES 

of  two  pounds  to  each  1,000  cubic  feet.  Damage  may  be  done  to  metals 
and  delicate  fabrics. 

If  the  mosquito  cannot  be  destroyed,  the  individual  may  be  kept 
from  their  attack.  This  has  a  double  significance.  It  prevents  the 
man  from  becoming  infected,  or  being  infected,  from  infecting  the 
mosquito  to  pass  it  on  to  another  man. 

Isolation  may  be  effected  by  the  use  of  screens  in  windows  and 
doors.  Copper  wire  screens  are  best,  18  meshes  to  the  inch;  mosquitoes 
will  pass  through  a  coarser  mesh.  Also  by  choosing  a  room  in  the  upper 
stories  for  a  sleeping  room.  If  the  individual  lives  in  a  badly  infected 
district,  he  should  avoid  going  out  after  sunset  or  before  sunrise  unless 
his  head  is  protected  by  a  veil  worn  over  the  hat,  his  hands  by  gloves 
and  his  ankles  by  boots.  In  the  tropical  forests  such  precautions  are 
necessary  even  by  day. 

Applications,  such  as  oil  of  pennyroyal,  oil  of  eucalyptus,  cam- 
phor, citronella,  may  be  made  to  the  skin,  the  odor  of  which  is  said  to 
keep  the  insects  away,  but  these  are  not  trustworthy. 

3 

Oil  of  Pennyroyal 

Oil  of  Citronella aa  §i  (  30.0  c.c.) 

Alcohol  or  Spirits  of  Camphor § viii          (240.0  c.c.) 

M. 

S.    Apply  locally. 

Epsom  salt  one  part  in  two  parts  of  water  dabbed  on  exposed  parts 
and  allowed  to  dry  has  been  recommended. 

Quinine  Prophylaxis.  Going  into  malarious  districts,  at  the 
season  of  the  year  when  infection  occurs,  or  if  living  in  malarious  dis- 
tricts, prophylactic  doses  of  quinine  should  be  taken:  gr.  ii  (0.120 
Gm.)  three  times  a  day  or  slightly  larger  doses,  gr.  vii  to  x  (0.50-0.60 
Gm.)  two  or  three  times  a  week. 

Wellman  recommends  gr.  xv  (1  Gm.)  on  two  successive  days  of  each 
week  for  a  period  of  two  months.  Various  modifications  of  these  in- 
terrupted doses  have  been  recommended. 

It  must  be  insisted  that  such  prophylaxis  is  by  no  means  as  effectual 
alone  as  when  combined  with  protection  and  the  latter  should  never  be 
neglected  if  it  is  possible  to  carry  it  out. 

Moreover,  giving  quinine  in  small  doses  and  interrupted  doses  induces 
quinine  immunity  on  the  part  of  the  infecting  organisms,  so  that  when 
symptoms  of  malaria  develop  it  has  been  repeatedly  observed  that  these 
cases  are  harder  to  cure  with  quinine,  last  longer,  need  more  quinine  and 
are  more  prone  to  relapse  than  those  who  had  had  no  prophylactic 
treatment. 


MALARIA  343 

Finally,  as  the  infection  may  die  out  of  itself  in  certain  instances, 
we  know  that  the  body  has  the  power  of  elaborating  protective  sub- 
stances, so  that  it  may  repel  lesser  infections  and  mitigate  severe  ones. 
To  do  this  the  body  must  otherwise  be  in  good  health  and  all  measures 
aimed  at  excellent  physical  condition  should  be  considered  for  those 
living  in  exposed  districts. 

Alcohol  does  harm  and  it  should  not  be  used  in  the  tropics  at  all. 
Arctic  explorers  tell  us  it  should  not  be  used  in  the  North,  so,  it  would 
seem  that  the  temperate  zone  would  have  a  hard  battle  to  justify  its 
designation. 

Finally,  the  malarial  organism  is  attacked  in  the  body  of  the  man, 
by  the  use  of  quinine,  before  it  has  had  time  to  multiply  and  give  rise 
to  the  characteristics  of  the  disease. 

Carriers.  It  is  important  in  malarial  districts,  that  carriers 
who  may  not  be  manifesting  evidences  of  the  disease,  should  be  detected. 
Blood  examinations  must  determine  that. 

These  cases  should  be  given  15  grains  of  quinine  for  two  to  three 
successive  days  each  week  for  three  weeks. 

BLACKWATER  FEVER 

It  is  not  becoming,  nay,  it  is  dangerous  for  me  who  have  had  no 
practical  experience  with  this  condition  to  write  dogmatically  of  its 
treatment. 

The  great  uncertainty  among  those  who  have  had  an  abundant 
opportunity  to  study  the  disease  should  lead  a  practitioner  taking  up 
tropical  work  to  review  the  literature  with  care. 

For  the  student  I  will  merely  outline  a  conservative  view  of  its 
therapy. 

The  condition  gets  its  name  from  the  hemoglobinuria,  one  of  its  most 
obvious  symptoms. 

The  whole  picture  seems  to  be  a  tremendous  hemolytic  crisis,  and 
although  some  writers  have  been  inclined  to  look  upon  it  as  an  entity 
separate  and  independent  of  malaria,  this  view  can  scarcely  be  main- 
tained and  malarial  infection  seems  to  be  the  sine  qua  non,  a  direct 
etiological  agent.  Such  an  expression  of  malarial  infection,  however, 
needs  the  intercalation  of  yet  another  cause  or  causes  for  its  eventuation. 
These  have  been  offered,  from  vague  conjectures  (see  anemia,  above) 
to  conclusions  derived  from  experiment;  for  example,  Bass  and  Johns, 
noting  the  effect  on  hemolysis  of  calcium  salts  added  to  their  cultures, 
have  surmised  that  an  increase  of  these  salts  in  food  and  drink  might 
be  etiologically  concerned  in  Blackwater  Fever.  Wade  Brown,  study- 


344  TREATMENT  OF  ACUTE  INFECTIOUS  DISEASES 

ing  the  effects  of  alkaline  hematin,  has  considered  -it  an  hemolytic 
element.  Others  have  conjectured  a  different  infection  from  malaria, 
such  as  a  piroplasm  or  a  chlamydozoal  body.  Still  others  have  hypothe- 
sized an  acidosis  affecting  the  liver,  findu^  support  in  the  observation 
that  the  condition  is  more  commonly  provoked  on  the  administration 
of  'acid  salts  of  quinine  than  when  the  latter  is  administered  with  a 
base.  The  views  of  Koch  and  others  of  the  part  played  by  quinine  in 
inducing  the  onset  are  well  known. 

Certainly  chilling,  exposure  to  sun,  fatigue,  and  alcoholic  excesses 
play  a  r61e. 

It  would  seem  as  if  individuals,  especially  Europeans  in  the  Tropics 
who  have  had  repeated  attacks  of  malaria,  had  acquired  a  lessened 
resistance  on  the  part  of  their  red  cells,  which  renders  them  more  sus- 
ceptible to  whatever  toxic  influences  prevail  in  malaria  or  to  some  such 
factors  as  obtain  in  paroxysmal  hemoglobinuria  or  to  an  anaphylactic 
reaction  or  even  to  the  harmful  effects  of  certain  salts  of  quinine.  The 
form  of  infection  is  almost  always  the  malignant  tertian,  plasmodium 
falciparum. 

Old  infection,  chilling  and  quinine  administration  seem  to  be  the 
most  common  factors  in  the  disease. 

However,  the  role  of  quinine  must  not  be  misunderstood,  as  it  alone 
is  apparently  not  a  sufficient  cause;  its  inefficient  use  both  prophylacti- 
cally  and  therapeutically  in  malarial  infection  is  largely  contributive 
to  the  condition. 

Symptoms.  Its  cardinal  symptoms  are  chill,  fever,  bilious  vomit- 
ing, with  distress  in  the  epigastrium,  sweating,  jaundice,  early  and  in- 
tense, and  hemoglobinuria. 

Both  liver  and  spleen  are  somewhat  enlarged  and  tender.  Anemia 
develops  rapidly.  Most  serious  symptoms  are  the  development  of 
hiccough  and  anemia. 

Treatment.  All  rules  applicable  to  the  treatment  of  malaria 
(barring  quinine)  are  indicated  here,  except  that  the  insistency  on  rest 
must  be  greatly  emphasized  and  the  patient  considered  as  having  sus- 
tained a  severe  hemorrhage  (as  indeed,  he  has). 

Stimulation  is  often  needed  and  must  be  vigorous. 

Quinine.  As  regards  the  administration  of  quinine,  we  are 
advised  to  use  it  vigorously,  we  are  advised  to  use  it  cautiously,  we  are 
advised  to  use  it  only  when  the  parasites  are  found  in  the  peripheral 
circulation,  and  we  are  advised  not  to  use  it  at  all. 

Personally  I  am  much  influenced  by  the  attitude  of  Lovelace  (see 
Archives  of  Internal  Medicine,  June,  1913),  which  seems  safe  and  sane 
and  based  on  a  considerable  experience. 


MALARIA  345 

He  has  been  impressed  as  have  others,  by  the  sequence  of  quinine 
administration  and  outbreak  of  the  hemoglobinuria,  by  the  fact  that 
it  has  never  occurred  in  his  experience  in  the  initial  attack,  but  always 
in  cases  of  relapse  and  in  weakened  individuals  and  in  those  who  took 
their  quinine  irregularly  as  a  prophylactic  or  insufficiently  when  at- 
tacked. 

He  would,  then,  under  no  circumstances  give  quinine  during 
an  attack  of  Blackwater  Fever  nor  for  several  days  after,  not  until  the 
urine  has  cleared  up,  hemoglobin  casts  no  longer  being  seen  and  the 
icterus  quite  or  nearly  cleared  up. 

Then  an  effort  to  stamp  out  the  malarial  infection  is  made  by  using 
quinine  with  great  caution. 

He  begins  with  1  grain  doses  (0.065  Gm.)  of  quinine  tannate  (be- 
cause one  of  the  weakest  salts)  three  times  a  day,  and  gradually  works 
up  to  20  or  30  grains  (1.30-2  Gm.)  of  the  hydrochloride  daily. 

Those  who  believe  that  it  is  especially  the  acid  salts  that  provoke 
the  hemoglobinuria  confine  themselves  to  the  quinine  base  or  the  tan- 
nate. The  treatment  thus  becomes  largely  symptomatic.  For  the 
chills,  fever  and  sweating,  as  in  the  ordinary  type,  measures  to  alleviate 
discomfort  are  pushed. 

Alkaline  waters,  such  as  vichy  or  plain  water  are  given  freely,  if 
vomiting  does  not  prevent.  Vomiting  may  be  treated  as  under  malaria. 
If  the  attack  is  severe  and  vomiting  continuous,  hypodermoclysis, 
enteroclysis  and  saline  infusion  with  normal  salt  is  indicated.  When 
food  is  long  rejected  glucose  into  the  veins  may  be  needed  to  maintain 
nutrition. 

If  an  acidosis  is  determined,  alkalis  should  be  administered.  (See 
Pneumonia,  Chap.  IX  ).  In  anuria  hot  fomentations  and  cups  are  ap- 
plied over  the  kidney.  When  quinine  is  deemed  unsafe,  neo-salvarsan 
has  been  advocated  and  some  good  results  seem  to  have  been  obtained. 

Prophylactic.  The  daily  use  of  quinine  gr.  vi  to  x  (0.40-0.60 
Gm.)  or  gr.  xv  once  or  twice  a  week,  and  an  efficient  treatment  of  initial 
attacks. 

SUMMARY 

Rest  in  bed. 

Bed.    Preferably  single.    Hospital  type. 
Room. 

Well  ventilated. 

Upper  story  preferred. 

Screened. 

Freed  from  encumbrances. 


346,          TREATMENT  OF  ACUTE  INFECTIOUS  DISEASES 

Diet. 

Make  no  effort  to  feed  during  a  paroxysm,  very  light  diet,  only  fluids 

within  six  hours  of  a  paroxysm. 

In  intervals  of  paroxysms  semi -solid  food  of  simple  character. 
In  remittent  type  of  fever  (estivo-autumnal)  consider  caloric  needs 

and  protein  demands.    (See  Chap.  II.) 

Symptomatic  treatment  during  the  paroxysm. 
Care  of  the  bowels. 

Calomel,  gr.  iii-v  (0.20-0.35  Gm.)  or  in  divided  doses,  gr.  J4  (0.015 
Gm.)  every  quarter  hour  for  six  or  eight  doses. 

This  may  be  followed  in  three  to  four  hours  by  a  saline. 

Magnesium  sulphate  (Epsom  salt). 

Sodium  sulphate  (Glauber's  salt),  or 

Sodium  and  potassium  tartrate  (Rochelle  salt)  5ss.-5i  (15-30  Gm.) 
in  half  to  three-quarter  glass  of  water. 

Best  time  to  give  cathartic  is  between  the  paroxysms,  but  before 

the  quinine. 
Chill. 

Heat. 

Hot  water  bags  or  bottles  to  feet. 

Flannels  about  the  extremities. 

Blankets. 

Hot  drinks,  water,  weak  tea,  lemonade,  whiskey  or  brandy. 

Codeine  phosphate,  gr.  ss.  (0.030  Gm.)  by  mouth.    Spirits  of  chloro- 
form, 5i  (4  c.c.)  in  water. 
Vomiting. 

Effervescing  drinks,  charged  water,  champagne. 

Mustard  paste  to  epigastrium.  One  part  of  mustard  to  three  or 
four  of  flour;  mix  with  cold  water,  spread  between  linen  or 
cheesecloth,  leave  on  ten  to  fifteen  minutes  or  until  well  red- 
dened. 

Bromides  in  10  to  15  grain  doses  (0.66-1  Gm.)    spirits  of  chloro- 
form, 3i  (4  c.c.)  in  water. 
Retching. 

Draughts  of  warm  water. 

Bicarbonate  of  soda,  3j  (4  Gm.)  in  a  glass  of  warm  water. 
If  very  severe. 

Morphine  hypodermically,  gr.1/12-1/8  (0.005-0.008  Gm.). 
Collapse. 

Hot  drinks,  coffee,  brandy,  whiskey,  aromatic  spirits  of  ammonia 
3i  (4  c.c.)  in  5ii-iv  (60-120  c.c.)  water. 

Strong  water  of  ammonia  to  inhale. 
Fever. 

Cold. 

Cracked  ice  to  suck. 

Cold  water,  cold  lemonade. 

Cool  sponges  of  water  or  water  and  alcohol. 

Light  rubs  with  25  per  cent,  alcohol. 


MALARIA  347 

Headache. 

Cold  cloths  to  forehead. 

Ice  bag  to  head. 

Codeine  phosphate  M  to  ^  grain  (0.015-0.030  Gm.)  doses  by  mouth 
or  hypodermically;  or, 

If  intense,  morphine  hypodermically,  gr.  1/24  to  gr.  1/12  (0.003- 

0.005  Gm.) 
Sweating. 

Change  night-dress  and  sheets. 

Rub  body  with  dry  towels. 

Drinks  of  water  and  lemonade. 
Collapse.    (See  under  Chill,  in  Summary.) 

Specific  treatment. 

Quinine. 

May  be  given  a  few  hours  before  an  expected  paroxysm. 
May  be  given  at  the  decline  of  the  fever  of  the  paroxysm,  or  may 

be  divided  into  two  or  more  doses  during  the  day. 
Oral  administration. 

Give  in  capsules,  each  gr.  ii  (0.15  Gm.),  or 

Give  in  solution;  bihydrochlorate  is  very  soluble;  bisulphate  1  in 
10;  or  dissolve  sulphate  in  any  dilute  acid,  dilute  sulphuric,  aro- 
matic sulphuric,  dilute  hydrochloric,  phosphoric  or  tartaric,  m.  i  per 
gr.  i. 

Good  method. 

Dissolve  the  dose  in  a  few  grains,  e.  g.,  gr.  x  (0.60  Gm.)  citric 
acid  in  lemon  juice,  add  water  and  a  pinch  of  bicarbonate  of  soda 
and  drink  effervescing. 
Dosage. 

Gr.  xxx  (2  Gm.)  of  quinine  a  day.  until  the  paroxysms  cease,  then 

gr.  xx  (1.30  Gm.)  a  day  for  ten  days  to  fourteen  days,  then 

gr.  xv  (1  Gm.)  on  two  successive  days  (e.  g.,  Saturday  and  Sunday) 

each  week  for  two  months. 
Doses  may  be  divided  as  gr.  xv  (1  Gm.)  twice  a  day,  or  gr.  x  (0.60 

Gm.)  three  times  a  day;  or 

10  grains  (0.66  Gm.)  three  times  a  day  for  three  days,  then 
10  grains  (0.66  Gm.)  each  night  for  8  weeks  without  intermission. 
(Bass.) 

In  tropics. 

15  grains  (1  Gm.)  three  times  a  day  for  a  week  or  until  temperature 
is  normal  for  5  or  6  days;  then  10  grains  (0.66  Gm.)  three  times  a 
day  for  10  or  12  days  (Stitt  in  Canal  Zone),  or: 

30  grains  (2  Gm.)  daily  until  symptoms  have  disappeared  and  plas- 
modia  are  no  longer  found;  then  15  grains  (1  Gm.)  daily  for  2 
weeks;  then  10  grains  (0.66  Gm.)  daily  for  2  months  at  least. 
(Vedder.) 

Bethea's  method.     (See  text.) 

Avoidance  of  inducing  "quinine  fastness"  in  organisms  by  insufficient 
early  dosage.  (See  text.) 


348  TREATMENT  OF  ACUTE  INFECTIOUS  DISEASES 

Quinine  in  children. 

Gr.  i  (0.060  Gm.)  three  times  a  day  for  each  year  of  the  child's 
age  or,  better,  larger  doses. 

(Holt)     Infants  one  year,  gr.  8  to  12    (0.50-0.75  Gm.),    five-ten 
years,  almost  as  much  as  adult  doses. 

(Bass)  Infants  under  1  year — %  grain  (0.030  Gm.) ;  1  year,  1  grain 
(0.060  Gm.);  2  yrs.,  2  grains  (0.012  Gm.) ;  3-4  yrs.,  3  grains  (0.2 
Gm.);  5-7  yrs.,  4  grains  (0.25  Gm.)  each  night  in  aromatic 
syrup  of  Yerba  Santa.  8-10  yrs.,  6  grains  (0.50  Gm.)  in  capsules 
as  adults.  Above  14  yrs.,  adult  doses.  Doses  kept  up  for  8  weeks. 

Give  quinine  in  solution  by  the  mouth  to  infants. 

To  small  children  give  in  syrup  of  Yerba  Santa  or  by  rectum  in  two 
to  three  times  the  oral  dose.    Give  in  solution  or  starch  paste. 

or 

Quinine  sulphatis,  gr.  xxx  (2  Gm.). 
Ft.  chart.  No.  xviii. 
S.  Six  (6)  powders  in  chocolate  syrup  each  day  as  directed.  (Bethea). 

Treatment  of  pernicious  infections. 

Quinine,  gr.  x  (0.60  Gm.)  three  times  a  day.  (Rogers). 
Quinine,  gr.  xv  (IGm.)  three  times  a  day  for  at  least  ten  days.  (James.) 
Quinine,  gr.  xx-xxx  (1.30-2  Gm.)  for  an  initial  dose,  followed  by  gr. 
x-xx  (0.60-1.30  Gm.)  every  four  hours  until  attack  clears  up  (one 
to  four  days),  then  gr.  xx  a  day  for  a  series  of  days.     (Wellman.) 
The  evidence  is  in  favor  of  the  liberal  dose. 
Very  severe  forms,  comatose,  choleraic,  algid,  etc. 
Quinine,  subcutaneously,  intravenously,  or  intramuscularly;  must  be 

very  dilute,  1  in  20-30  or  more. 

Subcutaneously  or  intramuscularly.    The  latter  is  always  to  be  pre- 
ferred. 
Use  dihydrochloride;  e.  g.,    quinine  dihydrochloride,  5  Gm.,  distilled 

sterile  water  10  c.c. 

Use  m.  xv  (1  c.c.)  of  above  diluted  in  water  to  Siiss.  (10  c.c.)  or 
better,  to  BSS.  (15  c.c.)  or  5i  (30  c.c.).  Never  more  than  10  per 
cent,  solution.  Inject  slowly  into  the  muscle  or  loose  subcutane- 
ous tissue. 

Quinine  and  urea  hydrochloride — use  in  same  way. 
Total  daily  dose,  gr.  xxiv-xlv  (1.60-3  Gm.). 
Hypodermoclysis. 

Use  gr.  xv  (1  Gm.)  of  the  hydrochloride  of  quinine  or  the  bimuriate 
of  quinine  and  urea  in  2  to  3  pints  (1,000-1,500  c.c.)  of  salt 
solution  (5i  to  Oi)  (4  Gm.  to  500  c.c.)  and  allow  to  flow  slowly 
from  an  irrigator  or  sterilized  fountain  syringe  into  loose  tissue 
under  breasts,  in  abdominal  wall,  loose  tissue  of  flanks.  Tempera- 
ture at  needle  should  be  about  100°  F.  A  short,  large  calibred 
tube  from  irrigator  lessens  loss  of  heat. 

This  is  particularly  indicated  in  choleraic  cases  and  in  collapse. 
Intravenous  use. 

High  dilution,  one  in  twenty,  better  thirty  or  more.    (See  text.) 
Any  highly  soluble  form,  as  above. 
Dose,  gr.  viiss.-xxx  (0.50-2  Gm.). 


MALARIA  349 

For  example. 

Hydrochloride  of  Quinine 0.5  Gm.  (gr.  viiss.) 

Sodium  Chloride 0.25  Gm.  (gr.  iii.) 

Distilled  Water 30  c.c.  (5i.) 

Inject  into  basillic  vein  made  prominent  by  ligature. 

Other  veins  may  be  chosen. 

(For  details  of  technique,  see  Rheumatism,  Chap.  III.) 

Bass  thinks  10  grains  (0.66  Gm.)  enough — more,  dangerous.  (For 

his  technique,  see  text.) 
Repeat  above  doses  by  vein  at  2  or  3  up  to  6  hour  intervals  until 

improvement   makes   oral   medication   feasible.     This   usually 

occurs  in  24  hours. 
(Quinine  solutions  in  ampoules  ready  for  intravenous  use  are  now 

put  up  by  some  of  the  pharmaceutical  houses.) 
For  toxic  manifestations  (cinchonism  and  idiosyncrasies)  see  text. 
For  contraindications  see  text. 
Other  forms  of  quinine.     (See  text.) 
Idiosyncrasies — sensitization. 
Desensitization.    (See  text.) 

Treatment  of  collapse. 
Strophanthin,  1/2  mg.  (gr.  1/120)  into  vein. 

Symptomatic  treatment  of  pernicious  malaria. 
Cerebro-spinal  type. 

Comatose  type. 

Intravenous  quinine  therapy. 
Collapse. 
Stimulants. 

Strophanthin,  gr.  1/120  (0.0005  Gm.)  hypodermically. 
Caffeine  sodium  salicylate  or  caffeine  sodium  benzoate,  gr.  v 

(0.30  Gm.)  hypodermically. 
Camphor  (10  per  cent.-20  per  cent,  in  oil),  gr.  v  (0.30  Gm.) 

hypodermically. 

Strychnine  sulphate  or  nitrate,  gr.  1/30  (0.002  Gm.)  hypoder- 
mically. 
More  urgent  cases. 

Inhalations  of  strong  water  of  ammonia  on  towel. 
Adrenalin,  m.  xv  (1  c.c.)  intramuscularly  or  m.  iii  intravenously. 
Hyperpyrexia. 

Cold  baths  at  65°  F.  or  at  85°  F.-90°.F.  and  cooling  to  65°  F.  '1  . 
Ice  in  tub  to  keep  temperature  down. 
Sponge  head  with  cold  water  during  bath. 
Take  patient  out  at  102.5°  F.-1030  F. 

Algid  form. 

Heat. 

Hot  drinks;  water,  coffee,  lemonade,  brandy  or  whiskey. 
Hot  water  bottles  to  feet  and  extremities. 


350  TREATMENT  OF  ACUTE  INFECTIOUS  DISEASES 

Blankets. 

Hot  rectal  injections  105°  F.-1100  F.  of  water  or  salt  solution 
containing  strong  coffee. 

Choleraic  form. 

Same  as  algid,  with  hypodermoclysis  or  venous  infusion  of  warm 

salt  solution  (.6  per  cent.). 
Morphine— gr.  1/8-1/4  (0.008-0.015  Gm.). 

Bilious  remittent  fever.    See  text. 

Complications. 

Kidney.     (See  text.) 
Heart. 

Dilatation  is  a  rare  occurrence. 

Strophanthin  by  the   vein  1/2  nag.  (gr.   1/120)  or  digitalis  by  the 

same  method.    (See  Pneumonia,  Chap.  IX.) 
Lungs.    (See  text.) 

Sequelae. 

Extreme  nervousness. 

Morphine,  gr.  1/16-1/8  (0.005-0.008  Gm.). 

Keep  sharp  watch  on  exhausted  patients,  who  develop  psychoses. 

Anemia. 

Abundant  diet. 
Fresh  air. 

Change  of  surroundings. 
'  Iron  and  arsenic.    (See  below  under  Cachexia.) 

Relapses. 

More  resistant  to  quinine  than  initial  attack. 
Treat  intravenously. 
(See  above  in  Summary.) 

Latent  malaria. 

(See  text.) 

Masked  malaria. 

(See  text.) 

Malarial  cachexia. 

.  Remove  from  a  malarial  district  or  protect  from  further  infection. 

(See  Prophylaxis.) 
Quinine. 
Treat  as  rigorously  as  a  severe  initial  attack.     (See  Summary^ 

above.) 
If  this  does  not  answer  use  the  drug  intravenously  in  doses  of  gr. 

xxiiss-gr.  xxx  (1.50-2  Gm.)  a  day. 

When  slight  temperature  has  subsided  or  a  course  equal  to  that 
given  in  a  severe  initial  attack  has  been  administered. 


MALARIA  351 

Treat  anemia. 
Iron. 

Pills  of  carbonate  of  iron  (Eland's)  or  Vallet's  mass  (Massa  ferri 

carbonatis),  gr.  v  to  x  (0.30-0.60  Gm.)  three  times  a  day. 
Arsenic. 

Fowler's  Solution  (Liq.  potassii  arsenitis)  m.  iii  (0.2  c.c.)  three 
times  a  day,  increasing  m.  i  (0.060  c.c.)  a  day  up  to  m.  viii-x 
(0.50-0.75  Gm.)  three  times  a  day  or  to  point  of  tolerance 
(suffusion  of  eyes,  puffiness  under  eyes,  gastro-intestinal  dis- 
turbances) . 
Combined  iron  and  arsenic. 

3 

Massae  Ferri  Carbonatis 10.00         5iiss 

Acidi  Arsenosi 0.05         gr.  3/4 

Massa  fiat  in  pilulas  numero.  xxx,  dividenda. 
S.     One  or  two  three  times  a  day. 

Cacodylate  of  soda,  gr.  ss.  to  gr.  iii  a  day  for  7  to  14  days.  Give 
hypodermically.  This  may  be  repeated  after  an  interval  if 
needed. 

Nervous  manifestations. 

Strychnine  sulphate,  gr.  1/30  (0.002  Gm.)  three  times  a  day. 
Fresh  air. 
Abundant  diet. 
Cool  baths. 
Massage. 

Graduated  exercises. 

If  the  spleen  is  much  enlarged,  patient  should  be  warned  against 
possible  rupture  by  violent  exercise  or  effort. 

Substitutes  for  quinine. 
None  efficient. 

Methylene  blue,  gr.  viiss.  to  gr.  xv  (0.50-1  Gm.)  in  divided  doses. 
Arsenic. 

Fowler's  solution. 
Atoxyl. 
Soamin. 

Salvarsan.    Given  as  in  syphilis  at  weekly  intervals. 
X-ray  or  radium  treatment  of  the  spleen  as  an  adjuvant. 

Convalescence. 

(See  under  cachexia,  change  of  air,  diet,  hygiene,  iron,  arsenic,  etc.) 

Prophylaxis. 

Destruction  of  the  mosquito. 

Draining  marshes. 

Filling  in  depressions. 

Screening  receptacles  of  water. 

Kerosene  in  pools. 

Small  fish  and  tadpoles  in  ponds  and  pools  feed  on  the  larvae.      Keep 


352  TREATMENT  OF  ACUTE  INFECTIOUS  DISEASES 

grass  cut  around  dwellings  and  remove  small  bushes  from  immediate 
vicinity. 
Pyrethrum  and  sulphur.    (See  text.) 

Protection  of  the  individual. 
Education. 

Sleeping  in  upper  rooms. 
Screening  rooms. 

Avoid  going  out  after  sunset  and  before  sunrise  unless  protected. 
Head  with  veil. 
Hands  with  gloves. 
Ankles  with  boots. 

Applications  to  skin  (very  little  value).    (See  text.) 
Prophylactic  doses  of  quinine  most  important,  gr.  xv  (1  Gm.)  quinine 

on  two  successive  days  each  week  or  gr.  x  (0.60  Gm.)  every  day. 
Keep  body  in  good  health. 
Avoid  alcohol. 
Carriers. 

Should  be  given  15  grains  (1  Gm.)  of  quinine  for  two  or  three 
successive  days  each  week  for  3  weeks. 

Blackwater  Fever 
Treatment. 

All  rules  for  treatment  of  malaria  applicable  except  quinine. 

Use  of  quinine. 

l  Lovelace's  rules.    (See  text  for  detail.) 

No  quinine  during  the  attack  and  for  several  days  after.    Then  gr. 

i  (0.060  Gm.)  of  the  tannate  of  quinine  three  times  a  day  and 

gradually  work  up  to  gr.  xx-xxx  (1.50-2  Gm.)  of  the  hydrochloride 

daily. 

Treat  chills,  fever,  and  sweating  as  given  under  Malaria. 
Give  alkaline  waters  or  plain  water  freely. 
Vomiting. 

See  under  Malaria.    If  severe  and  continuous  (Hypodermoclysis,) 

enteroclysis  and  infusion  with  normal  saline  solution. 

If  food  is  long  rejected,  give  glucose  into  veins.  (See  Cerebro  Spinal 

Meningitis,  Chap.  XXV.) 
Acidosis. 

Administer  alkalines. 
(See  Pneumonia,  Chap.  IX.) 
Anuria. 

Hot  fomentations  and  cups  over  kidneys.  (For  technique  of  apply- 
ing fomentations  and  cups,  see  Scarlet  Fever  and  Pneumonia, 
Chaps.  XVII  and  IX.) 
Salvarsan. 

Has  been  used  in  place  of  quinine  when  latter  was  feared. 

Prophylaxis. 
Daily  use  of  quinine,  gr.  x  (0.60  Gm.),  and  an  efficient  treatment  of 

the  initial  attack. 
Relapses  and  chronic  cases  are  candidates  for  Blackwater  Fever. 


CHAPTER  XVI 

DYSENTERY— BACILLARY  AND  AMEBIC 

BACILLARY  DYSENTERY 

DYSENTERY  is  a  term  used  to  designate  a  morbid  condition,  char- 
acterized by  inflammation  of  the  colon  and,  occasionally,  of  the  lower 
end  of  the  small  intestine  as  well;  hence,  it  is  a  colitis  or  enterocolitis. 

It  is  an  acute  infectious  process  which,  on  etiological  grounds,  can 
be  divided  into  two  diseases:  (1)  Amebic  dysentery,  due  to  the  in- 
vasion of  the  mucous  membrane  and  neighboring  tissues  by  a  protozoon, 
the  Entamceba  histolytica,  and  (2)  bacillary  dysentery,  due  to  the 
pathogenic  action  on  the  same  structure  of  a  bacillus,  or  of  members 
of  a  group  of  bacilli,  spoken  of  as  the  Bacillus  dysenteriae. 

The  pathological  changes  of  either  type  have  certain  distinguishing 
marks  of  their  own;  the  symptoms  vary  somewhat  and  the  sequelae  are 
not  identical;  and  yet  the  two  are  so  nearly  alike  that  without  the  finer 
aids  to  diagnosis,  the  use  of  the  microscope  and  culture,  they  may 
readily  be  confused. 

The  bacillary  form  is  the  one  peculiar  to  this  climate  and  to  the 
United  States,  though  amebic  dysentery  is  every  year  more  frequently 
met  with  even  in  this  city  and  among  those  who  have  not  been  in  the 
tropics;  first,  because  the  stools  of  dysentery  are  constantly  more  care- 
fully examined  and,  secondly,  because,  since  the  acquisition  of  tropical 
possessions,  more  patients  are  invalided  home  to  disseminate  the  disease. 

In  1898  Shiga  in  Japan  announced  the  isolation  from  the  stools  of 
dysentery  patients  of  the  bacillus  etiologically  concerned.  In  1900 
Kruse  identified  the  same  organism  in  dysentery  cases  in  Germany; 
while  Flexner,  Strong  and  Muszson  in  the  same  year  announced  the 
finding  of  an  allied  organism,  having  some  cultural  and  serological 
differences  in  the  stools  of  dysentery  patients  in  Manila.  Other  bacilli 
with  certain  differences,  the  Y.  organism  of  Hiss,  have  since  been  re- 
ported and  during  the  late  war  still  others.  The  medical  service  of  our 
own  army  issued  four  different  sera  for  the  identification  and  treatment 
of  these  cases. 

Culturally  the  bacillus  dysenteriae  has  many  points  of  similarity 
to  the  typhoid  bacillus.  It  is  however  a  non-motile  organism  with 


354  TREATMENT  OF  ACUTE  INFECTIOUS  DISEASES 

certain  other  slight  morphological  variations.  The  two  main  types  of 
the  bacillus  dysenteric  are  the  acid  strains  of  Flexner-Strong  (pro- 
ducing acid  in  mannite  media)  and  the  non-acid  strain  of  Shiga-Krause 
(not  producing  acid  in  mannite  media). 

From  a  practical  standpoint  the  serological  differentiation,  that  is, 
the  power  of  a  serum  produced  through  a  given  strain  to  agglutinate 
bacilli  of  that  strain  is  more  important  than  the  cultural  and,  of  course, 
identifies  the  serum  to  be  used  therapeutically  at  the  same  time.  When 
the  serum  of  the  patient's  blood  is  used  to  agglutinate  the  stock  strains 
and  so  identify  the  invading  organism  it  must  be  remembered  that 
these  agglutinating  substances  in  the  serum  are  usually  not  marked 
before  the  sixth  or  seventh  day  of  the  disease. 

Diagnosis  is  determined  then  by  bacteriological  examination  of 
the  stools  early  in  the  disease  and  by  agglutination  tests  at  the  end  of 
the  first  week  and  after. 

Pathology.  The  process  is  an  acute  catarrhal  inflammation  of  the 
large  intestine  and,  in  the  tropics,  of  the  lower  parts  of  the  ileum  with 
congestion,  sero-purulent  exudate,  fibrin  formation  and  coagulation 
necrosis  with  superficial  ulcerations.  The  ulceration  is  more  intense  in 
the  neighborhood  of  the  ileo-csecal  valve,  sigmoid  flexure  and  rectum. 

The  short  incubation  of  two  or  three  days,  more  rarely  delayed  as  long 
as  seven,  the  rather  sudden  onset,  with  fever,  diarrhea,  colicky  pain  and 
tenesmus,  the  appearance  shortly  of  mucus  in  the  stools,  streaked  with 
blood,  later  looking  like  chopped  or  shredded  beef  that  has  been  washed 
out  in  water,  are  merely  mentioned  here  to  recall  what  the  condition  and 
symptoms  are  which  we  have  to  consider  in  the  treatment. 

There  is  a  moderate  leucocytosis  with  slight  polymorphonuclear 
increase;  exceptionally  the  lymphocytes  predominate. 

Therapy.  There  are  few  self-limited  infectious  diseases  that 
are  accompanied  by  such  continuous ,  nagging  discomfort  and  distress 
as  dysentery.  Our  ingenuity  is  exercised  to  the  utmost,  not  merely 
in  the  efforts  to  shorten  the  process,  but  even  in  attempts  to  afford 
some  comfort.  For  success  much  depends  on  ability  to  secure  rest. 

Rest.  One  might  assume  that  the  train  of  events  in  dysentery 
would  compel  rest,  and  so,  indeed,  in  severe  cases  it  does,  but  in  the 
cases  that  in  their  incipiency  promise  to  run  a  mild  course  it  is  often 
difficult  to  get  the  patient  to  bed;  and  his  failure  to  accede  to  such  advice 
may  determine  a  very  severe  process  in  what  might  otherwise  have 
been  relatively  benign. 

Rest  in  every  case  of  acute  infectious  diseases  is  desired  both  for  the 
body  at  large,  suffering  from  the  effects  of  the  toxins  of  disease  and  of 
pyrexia,  to  shelter  metabolism  by  avoiding  unnecessary  work  and  so 


DYSENTERY— BACILLARY  AND  AMEBIC  355 

diminishing  the  demand  for  food  to  meet  such  metabolic  needs  and 
sparing  the  organs  concerned  in  digestion,  assimilation  and  utilization  of 
these  foods,  but  also  for  the  particular  organs  or  tissues  that  chance  to  be 
the  sites  of  lesions  caused  by  the  disease;  in  this  case,  the  large  intestine. 
Now,  the  large  intestine  13  a  receptacle  for  certain  materials,  in  part 
passed  on  from  above,  in  part  excreted  from  its  walls.  In  this  material 
fermentative  and  putrefactive  processes  are  going  on  as  the  result  of 
bacterial  action.  From  this  material,  water  and  certain  substances  in 
solution  are  being  absorbed.  This  structure,  the  bowel,  is  in  a  condition 
of  active  muscular  exercise,  the  site  of  peristalsis,  of  a  swinging  pendulum 
movement,  and  finally  is  pressed  upon  and  massaged  by  contiguous 
structures  as  the  result  of  the  action  of  the  muscles  surrounding  the 
abdominal  cavity,  from  which  arises  so  great  benefit  from  walking  and 
gymnastics  directed  to  the  abdominal  muscles  in  constipation.  It  will 
be  our  effort  to  diminish  the  activities  of  the  large  intestine,  that  is,  to 
secure  rest.  By  putting  the  patient  to  bed  we  avoid  the  squeezing  and 
massaging  due  to  muscular  action  and  so  take  away  one  stimulus  to 
increased  peristalsis;  an  important  factor,  considering  the  hyperactivity 
of  this  function,  upon  which  the  frequency  of  the  movements  and  the 
colicky  pain  so  largely  depends. 

Even  the  bed  is  a  bed  of  unrest,  for  the  griping  pain  is  always  forcing 
the  patient  to  seek  some  position  to  relieve  it. 

Bed.  Far  more  work  is  to  be  done  about  this  bed  by  nurse 
or  attendant  than  about  the  bed  even  of  a  typhoid  fever  case.  The  con- 
stant use  of  the  bed  pan,  the  soiling  that  necessitates  changing  of  the 
bed  linen,  the  soothing  applications  to  be  made,  the  irrigations  to  be 
given,  all  demand  as  much  economy  of  effort  as  can  be  procured  by 
favoring  conditions  to  work  under.  The  bed,  then,  should  be  chosen 
with  care.  It  must  be  a  narrow  or  half  bed,  best  of  the  hospital 
type,  which  is  about  6  feet  6  inches  long,  36  inches  wide  and  24  to  26 
inches  high.  The  spring  of  woven  wire  must  be  stiff  and  the 
mattress  of  hair  preferably  firm.  Over  this  is  placed  the  sheet, 
long  enough  to  tuck  well  under  and  draw  smooth  and  taut.  If  the  surface 
of  the  mattress  is  not  smooth  a  folded  blanket  under  the  sheet  will 
make  it  so. 

Over  the  sheet  is  put  a  rubber-sheeting  that  should  extend  from 
the  pillow  to  the  bend  of  the  patient's  knees  and  wide  enough  to  tuck 
under.  Over  this  comes  the  important  draw-sheet,  a  long  sheet 
folded  lengthwise  and  laid  across  the  bed  covering  the  rubber-sheeting 
and  tucked  far  under  one  side.  This  sheet  can  be  drawn  toward  the 
other  side,  little  by  little,  to  afford  a  cool  fresh  surface  under  the  patient 
from  time  to  time,  or,  if  soiled,  can  be  replaced  without  remaking  the 


356  TREATMENT  OF  ACUTE  INFECTIOUS  DISEASES 

whole  bed.  Over  the  patient  is  placed  the  upper  sheet  and  one  or  two 
blankets  arranged  with  a  view  to  comfort. 

It  is  very  well  to  have  a  second  bed  of  the  same  kind,  to  which  a 
patient  can  ..be  drawn  while  the  mattress  and  clothes  of  the  first  are 
airing. 

Room.  Every  sick-room  should  be  large,  well  ventilated,  and 
should  get  sunshine.  As,  however,  the  disease  is  far  more  common  in 
the  summer  than  at  any  other  time  of  the  year,  it  is  well  to  select  a 
room  in  which  there  shall  be  shade  the  most  of  the  day.  Morning  sun 
and  afternoon  shade  are,  of  course,  ideal.  If  there  is  a  balcony  on 
which  the  patient  can  be  wheeled  it  will,  if  it  is  properly  screened,  serve 
as  the  best  room  possible  in  the  warm  season. 

A  bath  room  contiguous  to  the  sick-room  is  extremely  desirable, 
saving  much  labor  of  fetching  and  carrying  as  is  obvious. 

The  odors,  which  in  some  cases  are  very  offensive  to  the  patient  as 
well  as  to  attendants,  may  be  mitigated  by  good  ventilation,  by  the 
burning  of  joss-sticks,  or  by  one  of  the  many  deodorants  on  the  market, 
whose  claim  to  disinfect  the  community  when  a  few  drops  are  shaken 
here  and  there  must  not  be  taken  seriously. 

Remembering  that  this  is  an  infectious  disease,  that  the  infecting 
agent  is  exclusively  in  the  stool  and  that  the  transmitting  agent  is 
commonly  the  fly  contaminated  with  the  feces,  the  room  and  bath  room 
should  be  screened  and  war  waged  on  the  fly  with  every  instrument 
and  device  of  extermination. 

Nurse.  The  nurse  or  attendant  should  be  thoroughly  instructed 
as  to  the  source  of  danger  to  herself  and  to  others.  She  should  wear 
rubber  gloves  and  a  gown  whenever  handling  stools  or  cleansing  the 
patient  after  a  stool.  If  she  cannot  avail  herself  of  this  protection, 
she  should  carefully  clean  her  hands  with  especial  reference  to  her 
nails,  after  each  performance.  The  urine  does  not  contain  the  bacilli, 
but  the  stools,  bed  linen,  dishes  handled  by  the  patient,  bed  pan,  rectal 
tubes,  thermometer,  should  be  sterilized  just  as  in  a  case  of  typhoid 
fever.  (See  Typhoid  Fever,  Chap.  XIV,  for  details.)  All  food  left  by 
the  patient  should  be  promptly  burned. 

The  Physician.  He,  too,  should  protect  himself  by  rubber  gloves 
and  gown  when  examining  the  patient  and  inspecting  the  stools,  and 
carefully  disinfect  his  hands  on  leaving. 

Care  of  the  Body.  A  cleansing  bath  should  be  given  each  day, 
if  there  is  a  skilled  hand  to  administer  it  or  the  manipulation  does  not 
cause  too  much  exhaustion. 

It  is  given  between  blankets,  the  patient  divested  of  his  night-shirt, 
being  rolled  on  one  and  covered  by  another.  Soap  and  warm  water 


DYSENTERY— BACILLARY  AND  AMEBIC  357 

at  110°  F.  is  used,  one  part  of  the  body  after  the  other  being  exposed 
and  attended  to  and  then  dried. 

The  feet  may  be  placed  in  a  small  foot-tub  in  the  bed,  the  knees 
being  drawn  up.  After  the  bath  the  skin  may  be  rubbed  with  alcohol 
and  dusted  with  drying  powder— one  of  the  numerous  talcum  or  toilet 
powders  in  use. 

An  approximation  to  this  detail  can  be  attained  by  an  attendant 
in  the  family,  if  care  is  exercised. 

The  mouth  should  be  attended  to  by  rinsing  after  every  feed- 
ing and,  if  in  bad  shape,  carefully  cleansed  by  gauze  or  absorbent  cotton 
around  the  finger  of  the  nurse  or  on  some  applicator  after  dipping  into 
some  cleansing  solution,  like  boric  acid  2  per  cent,  to  4  per  cent., 
a  Dob  ell's  solution,  or  half  strength  Listerine  antiseptic  solution 
N.  F.  If  very  bad,  peroxide  diluted  one-half  with  water  or  salt  solution 
may  be  used  before  the  mouth-wash. 

When  the  mouth  is  very  dry,  equal  parts  of  liquid  petrolatum 
(albolene)  and  2  per  cent,  boric  acid  solution  with  a  little  lemon 
juice  gives  relief.  Glycerin  is  sometimes  used,  but  if  the  mouth 
is  very  dry,  it  may  be  aggravated  by  the  glycerin  which  takes  up  water 
so  readily. 

Constancy  of  attention  and  patience  are  needed  to  nurse  these  cases 
properly,  because  the  restless  patient  is  disarranging  the  clothes  and 
seeking  a  comfortable  position  every  moment.  The  knees  are  often 
drawn  up  to  lessen  the  tension  of  the  abdominal  muscles,  a  hard  position 
to  maintain  as  the  feet  slip  on  the  smooth  sheet.  A  folded  blanket  or 
pillow  under  the  knees  gives  comfort,  or  a  foot  rest  placed  at  the  bottom 
of  the  bed.  These  devices,  however,  are  equally  unsatisfactory.  A  gatch 
bed  (see  index)  raised  to  support  the  knees  is  much  more  satisfactory,  but 
when  the  stools  are  frequent,  constant  lowering  to  place  the  bed  pan, 
makes  it  an  onerous  undertaking. 

Rings  and  air-cushions  may  be  needed  to  take  the  pressure  off 
the  bony  parts  daily  becoming  more  accentuated. 

Nothing  is  more  striking  and  real  than  the  intangible  something  we 
call  the  "atmosphere"  of  the  room,  and  it  is  the  ability  of  the  trained 
hand  to  secure  order,  neatness,  quiet  and  calm  that  gives  courage  both 
to  the  patient  and  doctor. 

Frequent  visitors,  garrulous  friends,  Job's  comforters,  pedlars  of 
similar  experiences,  id  genus  omne,  are  to  be  excluded  as  a  part  of  the 
treatment. 

The  bed  pan  in  this  disease  is  the  most  important  article  in  our 
armamentarium,  and  its  skilful  use  is  imperative.  The  distressing  con- 
dition that  obtains  in  some  of  these  cases  is  hard  to  appreciate  unless 


358  TREATMENT  OF  ACUTE  INFECTIOUS  DISEASES 

witnessed.  I  have  seen  stools  coming  every  fifteen  minutes  with  tenes- 
mus  that  deprived  the  patient  of  all  sense  of  relief  after  the  stool,  and 
keeping  up  for  hours,  until  the  patient  begged  that  the  pan  be  not 
removed  at  all. 

The  pan  should  be  warmed  before  using,  the  patient's  knees  flexed 
and  a  hand  placed  under  the  lower  part  of  the  back  to  raise  him.  The 
same  thing  is  done  on  taking  the  pan  away.  Either  a  clean  pan  can  then 
be  slipped  under  the  patient  or  a  towel  may  be  placed  under  the  pan  to. 
begin  with,  upon  one  or  the  other  of  which  the  patient  lies  while  the  parts 
are  carefully  cleansed,  dried,  rubbed  with  alcohol  and  dusted. 

It  is  very  essential  in  this  disease  that  the  patient's  body  and  ab- 
domen should  be  kept  warm,  as  chilling  aggravates  the  diarrhea. 
Woolen  material  should  be  worn  over  the  abdomen.  If  the  feet 
are  cold  the  hot- water  bottle  is  to  be  used. 

Diet.  During  the  first  few  days  of  the  attack,  when  the  stomach 
is  often  very  sensitive  to  food,  and  nausea  and  vomiting  are  a  feature, 
and  while  the  evidences  of  intoxication  are  most  marked  and  peristal- 
sis most  active,  the  quantity  of  food  is  of  less  importance  than  the 
quality. 

The  food  must  be  bland,  non-irritating  and  non-stimulating  to  the 
gastro-intestinal  tract,  must  be  readily  assimilable  and  leave  but  little 
residue,  and  must  be  concentrated,  especially  with  reference  to  its  pro- 
tein content.  All  these  conditions  are  met  by  milk  better  than  by  any 
other  food. 

It  has  been  my  lot  to  have  a  great  many  cases  of  dysentery  to  treat. 
Most  of  them,  to  be  sure,  were  of  the  moderate  type,  but  not  all. 

It  has  been  my  routine  to  put  the  patient  on  a  milk  diet,  order- 
ing the  milk  boiled  and  given  every  two  hours,  the  patient  is  to  take  what 
he  will  of  8  ounces. 

Why  boiled  milk  should  be  any  better,  if  as  good,  as  clean  raw  milk 
in  this  condition,  I  cannot  offer  adequate  explanation.  I  can  only  plead 
handing  a  leaf  out  of  the  book  of  my  own  experience.  If  the  patient 
prefers  it  raw,  or  boiled  milk  distresses  him,  I  do  not  persist  in  my  prej- 
udices. At  the  beginning  of  the  attack,  especially  if  there  is  much 
fever,  I  dilute  it  1/4  or  1/3  with  plain  boiled  water,  or  barley  water  or 
rice  water.  Preferably  plain  water.  If  there  is  a  coated  tongue  or  flatu- 
lence or  the  milk  does  not  seem  well  borne,  I  suspect  that  the  fat  is  not 
well  borne  and  have  the  milk  skimmed. 

I  believe  the  experience  of  our  pediatric  practice  with  reference  to 
intolerance  for  fats  can  afford  us  practical  information  in  its  usage  in 
adults. 

When  the  temperature  disappears  and  the  stools  have  Tost  their 


DYSENTERY— BACILLARY  AND  AMEBIC  359 

diarrheal  character,  one  may  allow  barley  jelly,  and  thoroughly  boiled 
rice;  later,  toast,  then  an  egg,  then  a  chop  and  then  gradually  the  re- 
sumption of  a  normal  diet. 

When,  however,  a  case  runs  a  chronic  course,  the  same  needs  for 
sufficient  foods  to  make  good  the  body  losses  prevail  as  in  typhoid 
fever.  These  will  be  taken  up  shortly. 

All  food  should  be  given  warm,  for  if  cold  or  very  hot,  peristalsis  is 
aggravated. 

I  am  aware  that  many  will  take  exception  to  milk  as  the  main  article 
of  diet  in  this  disease  and  especially  and  perhaps  with  more  justice  the 
pediatrician.  I  am  not  prepared  to  dogmatize.  Others  prefer  during 
the  acute  stages  only  albumin  or  rice  water  or  barley  water  sweetened 
with  lactose,  thin  chicken  broth,  tea  sweetened  with  lactose,  meat  juice, 
expressed  from  rare  steak;  while  the  exceptional  case  does  better  on  a 
diet  that  upsets  all  our  dietetic  theories;  casein  would  seem  appropriate 
in  infants.  If  the  milk  diet  I  have  suggested  does  not  agree,  one  may 
fall  back  on  such  a  diet  as  has  just  been  quoted. 

Milk  sugar  may  be  added  to  the  foods  given  so  as  to  increase  the 
caloric  value. 

If  there  is  much  gastric  disturbance,  all  foods  must  be  stopped, 
until  it  is  removed. 

Water  should  be  given  freely,  as  it  must  be  appreciated  that 
there  is  a  constant  and  great  loss  of  water  to  the  tissues.  It  should 
not  be  given  too  cold  or  in  too  large  amounts  at  once,  for  reasons  just 
expressed. 

Care  of  the  Bowels.  As  the  treatment  of  the  disease  resolves 
itself  pretty  much  into  the  treatment  of  the  bowel,  the  preliminary 
catharsis  only  will  be  touched  upon  here  and  the  rest  taken  up  under 
symptomatic  treatment. 

The  object  of  the  preliminary  catharsis  is  to  clean  out  the 
intestinal  canal  as  far  as  possible  before  beginning  treatment.  That 
the  patient  has  diarrhea  and  frequent  diarrhea  is  by  no  means  proof 
that  the  intestine  is  clear.  It  is  undoubtedly  Nature's  intent  that  it 
should  be,  and  the  diarrhea  is  but  an  expression  of  the  intestine's  effort 
to  rid  itself  of  irritation,  which  effort  may  be  futile  or  abortive,  without 
help. 

There  are  three  cathartics  especially  recommended  for  this  purpose; 
calomel,  salines,  and  castor  oil. 

Personally,  I  am  emphatically  in  favor  of  castor  oil.  I  prefer  it 
because  I  believe  it  as  effectual  as  the  others  in  evacuating  the  bowel; 
because  I  believe  it  less  irritating  than  the  others  and  because  I  am  con- 
vinced that  it  has  an  after-constipating  effect. 


360  TREATMENT  OF  ACUTE  INFECTIOUS  DISEASES 

A  paper  read  at  the  American  Pediatric  Association  by  Abt  of  Chicago 
dealt  with  the  study  of  the  effects  of  repeated  doses  of  these  three  cath- 
artics in  infants  in  doses  usually  used  in  diarrhea,  with  reference  to 
irritating  effects  produced,  as  expressed  by  the  presence  of  mucus  and 
occult  blood.  After  the  second  dose — the  doses  given  at  two-hour 
intervals — calomel  was  followed  by  increasing  amounts  both  of  blood 
and  mucus,  salines  by  less  and  castor  oil  by  least  and  but  little  unless 
in  large  and  long  continued  doses. 

I  would  not  convey  the  impression  that  this  occurs  in  the  adult  enough 
to  decry  their  use,  for  I  think  that  would  be  unfair. 

If  there  is  nausea  and  vomiting  accompanying  the  attack,  one 
gives  calomel  in  divided  doses,  gr.  1/4  or  gr.  1/10  every  ten  or  fifteen 
minutes  until  1  or  1  1/4  gr.  are  given,  for  the  anti-emetic  effect  of  the 
drug  as  well  as  its  cathartic;  then,  if  the  stomach  is  quiet,  give  the  oil, 
or  failing  that,  salts. 

Castor  Oil  never  was  looked  upon  as  a  delicacy  and  the  very 
sight  or  mention  of  it  so  keenly  associated  in  the  minds  of  many  with 
the  ordeals  of  childhood  that  it  is  flatly  refused  or  taken  under  bitter 
protest.  Because  of  this  fact,  so-called  tasteless  preparations  are  offered 
or  its  taste  is  covered  or  it  is  given  in  capsules. 

There  are  several  ways  of  giving  castor  oil  while  at  the  same  time 
disguising  its  taste,  and  this  may  be  so  successfully  done  at  times, 
as  to  make  it  desirable  to  administer  it  without  announcing  its  char- 
acter. Many  vehicles,  however,  like  hot  black  coffee,  sarsaparilla,  soda 
or  beer  are  unsuited  to  the  conditions  at  hand,  while  to  give  it  in  milk 
is  to  violate  a  rule  that  cannot  be  too  emphatically  insisted  upon — 
" never  give  disagreeable  medicines  in  a  food." 

The  disguise  is  not  complete  and  the  association  may  turn  the  patient 
against  an  important  food. 

An  excellent  method  is  to  put  a  teaspoonful  of  brandy,  whiskey,  wine, 
lemon-juice,  orange-juice,  pineapple  juice,  or  peppermint  water  in  a 
wine  or  egg  glass,  let  it  run  all  around  the  surface  to  wet  it,  pour  on  to 
that  5  teaspoonfuls  of  castor  oil  from  a  spoon  previously  wetted  in  hot 
water  to  let  it  run  easily,  over  the  oil  another  teaspoonful  of  the  same 
substance,  and  instruct  the  patient  to  take  it  quickly,  wiping  the  lips 
and  allowing  him  to  suck  an  orange  or  lemon. 

The  dose  is,  then,  J4  to  1  ounce. 

Specific  Treatment.  Serum.  It  is  difficult  as  yet  to  pass  judg- 
ment on  the  value  of  serum  in  bacillary  dysentery.  To  be  in  any  degree 
efficient,  the  serum  must  have  been  prepared  from  the  strain  etiologi- 
cally  concerned  in  the  individual  case.  One  would  naturally  expect 
better  results  from  serum  elaborated  against  that  strain  alone  than 


DYSENTERY— BACILLARY  AND  AMEBIC  361 

from  a  polyvalent  serum,  though  this  may  be  used  for  want  of  better. 
It  is  used  at  present  only  in  the  severe  cases,  and  then  only  after  a 
history  of  previous  serum  administration  or  of  asthma  has  been  con- 
sidered, a  test  for  sensitization  made  and  desensitization  precautions 
observed  (see  Pneumonia,  Chap.  IX  for  details  and  treatment  of  ana- 
phylactic  phenomena.)  The  dose  is  40  to  60  c.c.  of  serum  diluted  with 
equal  amounts  of  normal  saline  given  intravenously.  Doses  of  20^0 
c.c.  are  given  each  succeeding  day  if  deemed  necessary.  (For  technique, 
see  Pneumonia,  Chap.  IX.)  Polyvalent  serum  has  been  used  in  doses 
of  80-120  c.c.  into  the  subcutaneous  tissues.  Some  authorities  (Nolf — 
J.  A.  M.  A.,  Oct.  18,  1919,  Vol.  73,  No.  16)  find  vaccine  treatment  far 
more  efficacious  than  the  serum  treatment  in  acute  cases. 

Vaccine  Therapy.  The  vaccine  used  by  Nolf  in  the  Belgian 
army  in  1918  was  made  from  dysentery  baccilli  isolated  from  the  intes- 
tine wherever  possible.  When  autogenous  vaccines  could  not  be  made, 
a  vaccine  from  the  Flexner  bacillus  type  was  used.  No  vaccine  was 
used  of  the  Shiga  type.  He  gave  the  vaccine  in  every  case  which  did 
not  yield  in  one  week  to  dietetic  and  drug  treatment.  It  was  adminis- 
tered intravenously  at  four-day  intervals  in  very  small  doses  at  first, 
10,000,  increasing  slowly;  30,000,  50,000,  100,000  and  so  on.  In  cases 
of  moderate  severity  it  was  rarely  necessary  to  go  beyond  500,000  to 
effect  a  cure,  but  in  stubborn  cases  one  may  increase  to  10,000,000,  be- 
fore the  desired  result  is  attained.  Best  results  are  obtained  by  early 
treatment.  In  one  series  quoted,  there  was  a  complete  cure  in  a  few 
weeks'  time  and  only  2  deaths  among  500  cases  so  treated.  Fever  drops 
by  lysis  with  some  exacerbation  on  the  day  of  inoculations  and  the 
next  day  following.  Nolf  emphasizes  that  in  cases  thus  treated  in  1918 
they  were  able  to  avoid  the  tendency  to  chronicity  experienced  in  their 
cases  treated  in  1917. 

Empirical  Treatment.  One  drug  in  dysentery  has  given  me  more 
satisfaction  than  any  other,  and  that  is  castor  oil. 

The  following  prescription  advised  by  Dr.  Francis  Delafield  of  this 
city  has  been  especially  satisfactory: 


Olei  Ricini 10.  5   iiss. 

Phenylis  Salicylatis 2.50        gr.  xxxvii 

Tr.  Opii  Deodorati 1 .  m.  xv. 

M.  et  div.  in  capsulas  no.  xv. 
S.    One  every  two  hours. 

The  results  are  truly  most  gratifying  and  I  have  had  to  have  recourse 
to  no  other  prescription  in  a  large  series  of  cases  of  dysentery,  but  that 


362  TREATMENT  OF  ACUTE  INFECTIOUS  DISEASES 

does  not  include  the  severest  types  described,  or  the  tropical  variety 
(amebic) . 

One  capsule  is  given  every  two  hours  and  when  the  stools  begin  to 
diminish  materially,  one  every  three  hours  and  with  still  further  im- 
provement every  four  hours. 

I  believe  the  improvement  is  due  to  the  small  doses  of  oil,  for  the 
results  are  very  satisfactory  without  the  opium;  and  one  may  give  the 
prescription  without  the  opium  in  the  milder  cases  and  when  the  stools 
begin  materially  to  decrease  in  number.  The  small  dose  of  opium, 
equal  to  1/10  gr.  (0.006  Gm.)  does,  however,  adds  its  own  effect  and 
relieves  the  pain. 

I  am  not  convinced  of  any  particular  value  on  the  part  of  phenyl 
salicylate  (salol).  Perhaps  it  adds  its  own  anodyne  and  antipyretic 
effect;  any  antiseptic  virtue,  I  doubt. 

There  is  one  very  important  adjuvant  to  this  treatment,  also 
insisted  upon  by  its  advocate — namely,  the  administration  every  sec- 
ond day  or  at  least  every  third  day,  of  further  large  doses  of  castor  oil 
as  in  the  beginning. 

The  small  doses  are  unquestionably  constipating  and  the  diminu- 
tion of  the  stools  is  the  result  we  see,  as  well  as  improvement  in  their 
character.  We  have  to  remember  also  that  in  the  meantime  fecal  matter 
is  collecting,  mucus,  bacterial  toxins  and  bacteria  themselves  are  gather- 
ing, and  damage  from  these  sources  with  a  recrudescence  of  the  disturb- 
ance will  follow  unless  evacuation  is  attained  at  suitable  periods. 

Somewhat  similar  to  this  castor  oil  treatment  is  one  warmly  advo- 
cated in  some  quarters,  but  about  which  I  can  speak  less  authorita- 
tively; namely,  the  saline  treatment. 

Sodium  sulphate  or  magnesium  sulphate  is  given  in  a  half  ounce 
or  ounce  dose,  then  followed  by  one -dram  doses  of  the  salt  every  two 
hours,  three  hours  or  four  hours  as  improvement  occurs,  or  dram  doses 
every  hour  can  be  given  until  the  initial  catharsis  is  accomplished. 

Symptomatic  Treatment.  Pain.  Between  the  constantly  re- 
curring griping,  twisting,  colicky  pains  and  the  incessant  nagging 
of  the  tenesmus,  exhaustion  threatens;  so  that  the  symptom  is  one  of 
the  most  urgent  in  its  demands  for  relief. 

This  may  be  afforded  by  topical  applications  or  drug  administration. 

Heat  to  the  abdomen  is  one  of  the  best  measures  we  have  at 
our  command.  It  can  be  applied  in  the  shape  of  hot  fomentations, 
turpentine  stupes  or  thin  poultices. 

To  give  a  fomentation  take  two  pieces  of  thick  flannel;  an  old 
blanket  affords  just  the  material  we  want;  cut  into  squares  to  cover 
the  abdomen. 


DYSENTERY— BACILLARY  AND  AMEBIC  363 

Have  ready  in  addition  another  piece  of  flannel  for  a  cover  or  pro- 
tector and  a  towel  with  sticks  sewed  across  either  end  to  answer  as  a 
wringer. 

Lay  the  flannel  squares  in  the  towel,  pour  boiling  water  over  them, 
saturating  them  thoroughly  and  then  quickly  wring  out  in  the  towel 
by  twisting  the  sticks  in  opposite  directions  to  each  other.  The  wring- 
ing must  be  complete  and  no  water  be  left  in  the  flannel.  Take  this  out 
quickly,  shake  it  once  in  the  air,  place  it  on  the  abdomen  and  cover  with 
the  protector.  Before  the  fomentations  are  applied,  the  skin  may  well 
be  lubricated  with  vaseline. 

It  is  helpful  to  have  the  patient  in  a  blanket  which  can  be  brought 
up  over  the  fomentations. 

These  may  be  applied  every  ten  or  fifteen  minutes  until  relief  is 
afforded. 

Turpentine  stupes  are  prepared  in  much  the  same  way,  a  dram 
of  turpentine  having  been  added  to  the  hot  water  into  which  the  flan- 
nels are  to  be  dipped  or  the  stupes  may  be  sprinkled  with  a  little  tur- 
pentine after  they  have  been  wrung  out  or  a  bit  of  absorbent  cotton 
wet  with  turpentine  may  be  passed  lightly  over  the  abdomen  before 
the  stupes  are  applied.  Careless  application  of  the  turpentine  may 
result  in  a  burning  of  the  skin. 

The  frequency  of  application  and  the  length  of  time  they  are  to  be 
left  on  will  depend  on  the  reaction  of  the  skin  to  the  turpentine  and 
the  efficacy  of  the  measure. 

These  devices  not  only  lessen  the  spasm,  but  by  so  doing  diminish 
the  frequency  of  the  stools. 

Comfort  may  also  be  afforded  by  warm  rectal  irrigations,  at 
100°  F.  to  105°  F.  of  plain  water  or,  better,  physiological  salt  solution, 
one  teaspoonful  (1  dram)  of  salt  to  the  pint  (4  Gm.  to  500  c.c.). 

These  irrigations  are  considered  by  some  men  as  an  important  item  in 
the  treatment  of  the  inflamed  colon  and  are  especially  in  vogue  in  chil- 
dren's practice.  I  have  had  to  have  recourse  to  them  in  adult  practice, 
in  the  acute  stage  but  rarely,  finding  the  prescription  given  above  to- 
gether with  fomentations  sufficient. 

While  at  times  the  irrigation  does  good,  I  prefer  to  do  without  it  if 
possible,  because  it  can  be  overdone  and  one  feels  that  often  when  it  is 
done,  the  bowel  gets  more  excitation  than  rest  by  the  procedure. 

The  tenesmus  frequently  requires  drug  treatment  and  we  pre- 
fer to  give  it  locally  at  first.  This  can  be  done  by  the  suppository  con- 
taining gr.  ss.  (0.030  Gm.)  of  opium  or  in  more  severe  cases  by  the 
morphine  suppository  which  contains  gr.  1/4  (0.015  Gm.)  or  by  one 
combining  opium  and  belladonna,  e.  g. : 


364  TREATMENT  OF  ACUTE  INFECTIOUS  DISEASES 


Opii  Pulveris  ........................  gr.  i  (0.060  Gm.) 

Ext.  Belladonnae  fol  ..................  gr.  ^  (0.015  Gm.) 

Olei  Theobromatis  q.  s  ..............  -(gr.  xxx)  (2.  000  Gm.) 

M.  et  fiant  talia  suppositoria  no.  xii. 
S.    One  inserted  as  directed. 

Another  time-honored  method  of  using  opium  by  the  rectum  is  through 
the  medium  of  starch  mucilage. 

Give  m.  xv  (1  c.c.)  of  the  tincture  of  opium  in  an  ounce  or  two  of  the 
starch  preparation,  injecting  slowly.  In  an  irritable  bowel  the  smaller 
amount  is  more  easily  retained. 

There  are  cases  in  which  the  pain  is  too  great  to  be  relieved  by  these 
efforts,  and  morphine  has  to  be  used  hypodermically.  When  this  is  done, 
appreciate  that  a  fight  is  on  and  the  drug  habit  is  the  antagonist.  Use  it 
sparingly,  both  as  to  dose  and  periodicity,  and  take  the  evidences  of 
pain  rather  than  the  assertion  of  the  patient  as  the  criterion  of  its  usage. 

More  recently  benzyl  benzoate  in  20  per  cent,  alcoholic  solution,  10-30 
drops  three  times  a  day,  has  been  suggested. 

Diarrhea.  The  stools  of  dysentery  are  characteristic.  They  are 
small,  often  not  a  teaspoonful  at  a  time,  and  consist  of  little  clots 
of  mucus  for  the  most  part  blood-stained,  like  soaked  meat.  It  is  evi- 
dent that  these  stools  no  longer  represent  a  conservative  process,,  but 
are  the  simple  expression  of  the  inflammatory  process.  They  test  the 
limit  of  the  patient's  endurance.  They  have  to  be  controlled  or  rather 
the  bowel  must  get  the  rest  that  a  diminution  of  the  stools  bespeaks. 

Numerous  drugs  have  been  advised.  They  may  be  divided  into 
three  classes:  Astringents,  local  sedatives,  and  opium. 

I  do  not  like  the  first.  Astringents  operate  by  inducing  changes 
in  the  protoplasmic  substance  of  the  cells,  that  threaten  their  integ- 
rity. One  feels  that  it  is  heaping  Ossa  upon  Pelion  in  the  acute  process. 

I  pin  my  faith  on  the  last  two,  and  especially  opium. 

As  to  bismuth,  its  action  is  largely  protective,  though,  perhaps, 
to  some  slight  degree  partaking  of  the  astringent  properties  of  all  the 
heavy  metals.  If  it  is  the  purpose  to  coat  over  the  mucous  membrane 
with  bismuth,  or  even  if  this  theory  of  its  action  is  not  correct,  still 
experience  has  shown  that  to  do  real  good  it  has  to  be  used  in  large  doses. 
It  is  insoluble  and  non-toxic,  which  statements  may  stand  good  as  far 
as  they  influence  its  therapeutic  use. 

It  should  be  given  in  at  least  gr.  xxx  (2  Gm.)  doses  every  two  hours 
until  results  are  obtained.  The  easiest  way  to  give  it  is  in  powders.  A 
powder  in  a  little  water,  a  shake  which  diffuses  it  in  suspension  in  a 
second,  and  take  so. 


DYSENTERY— BACILLARY  AND  AMEBIC  365 

One  warning  must  be  offered  born  of  experience. 

Be  sure  that  at  least  every  second  or  third  day  the  bowel  is  emptied 
by  a  dose  of  castor  oil  or  salts,  for  these  large  doses  of  bismuth  collect 
in  the  bowel  and  by  sheer  weight  do  harm  to  the  gut.  One  of  my  most 
vivid  recollections  is  seeing  a  case  to  which  bismuth  had  been  given  for 
weeks  without  catharsis  and  with  the  continuance  of  the  symptoms  to  a 
point  of  dubious  prognosis. 

A  large  dose  of  oil  was  followed  by  movements  that  literally  filled 
the  bed-pan  with  black  masses  of  bismuth  that  looked  like  fresh  tar- 
concrete  and  must  have  weighed  pounds.  Recovery  started  from  the 
time  of  this  relief. 

Upon  opium  we  are  dependent  for  our  best  results. 

It  diminishes  peristalsis  and  so  the  cause  of  pain  and  tenesmus,  it 
diminishes  the  stools,  it  lessens  pain  and  permits  rest  and  sleep ;  rest  for 
the  bowel,  rest  for  the  body  and  rest  for  the  mind. 

There  are  three  things  that  should  be  emphasized  about  the  use  of 
opium  in  these  cases: 

1.  Never  use  it  until  the  bowel  has  been  efficiently  emptied  by  one 
of  the  cathartics  advised. 

2.  Use  it  in  the  smallest  amounts  that  will  get  results.    I  have  rarely 
had  to  use  it  in  greater  amounts  than  1/10  of  a  grain  (0.006  Gm.),  that 
is,  one  drop  of  the  tincture  every  two  hours. 

3.  Do  not  advise  the  patient  of  the  fact  that  you  are  using  it.    The 
profound  effects  of  opium  that  will  permit  him  to  appreciate  that  he  is 
getting  it  will  not  be  manifested  in  these  doses. 

Again  the  necessity  of  the  cathartic  at  intervals  of  two  or  three  days 
should  be  emphasized. 

Severe  cases  may  take  on  a  choleraic  character.  Beside  profuse  watery 
stools  causing  a  veritable  dehydration  there  is  vomiting,  cyanosis, 
weak,  rapid  pulse,  cold  extremities  and  muscular  cramps.  These  cases 
indicate  fluid  for  the  tissues. 

It  may  be  given  as  a  hypodermoclysis,  one  to  two  quarts  of  normal 
saline  solution  or  an  infusion  of  normal  saline  into  the  vein.  If  the 
stomach  will  retain  it,  fluids  by  the  mouth  are  pushed.  Heat  should  be 
applied  to  the  extremities,  morphine  in  doses  of  gr.  1/4  (0.015  Gm.) 
hypodermically  to  control  the  flux,  which  may  well  be  combined  with 
atropine  sulphate  gr.  1/150  (0.0004  Gm.).  Strophanthin  gr.  1/120  (1/2 
mg.)  given  into  the  vein  or  digitalis  administered  in  the  same  manner 
in  doses  of  3  to  5  grains.  Adrenalin  intramuscularly  in  doses  of  m.  x  to  xv 
at  quarter  hour  intervals  for  some  half  dozen  doses  to  sustain  the  blood 
pressure  or  small  doses  m.  ii-iii  cautiously  introduced  through  the  wall 
of  the  tube  of  the  infusion  apparatus  when  giving  the  saline  intrave- 


366  TREATMENT  OF  ACUTE  INFECTIOUS  DISEASES 

nously.  Hypertonic  glucose  solution  (25  per  cent.,  250  c.c.  or  Sviii) 
should  theoretically  be  of  value,  but  I  have  had  no  personal  experience 
with  the  measure. 

Heart.  In  severe  cases  the  myocardiura,may  be  seriously  damaged 
by  the  toxins,  which  induces  circulatory  failure;  digitalis  should  be 
used  to  digitalizing  effects.  For  details  of  circulatory  stimulants  and 
their  administration  see  Pneumonia,  Chap.  IX. 

Duration.  Most  cases  run  a  course  of  a  few  days  to  a  week  or 
a  trifle  more,  a  certain  number  continue  three,  four,  five  or  six  weeks 
and  then  cease  or  pass  over  into  a  chronic  form. 

Subacute  and  Chronic  Form.  When  a  case  is  passing  over 
into  a  chronic  form,  if  seen  for  the  first  time,  the  effects  of  such  medi- 
cation as  has  been  advised  may  be  tried  long  enough  to  test  its  worth. 

Vaccines.  The  same  vaccine  is  used  as  in  the  acute  cases.  The 
initial  dose  and  the  time  intervals  should  be  the  same  but  often  the 
final  dosage  must  be  raised  to  much  higher  figures — 5  and  10  billion. 
Nolf  thus  succeeded  in  effecting  complete  cures  even  in  the  most  chronic 
cases.  He  first  used  these  vaccines  subcutaneously  in  a  dosage  starting 
with  a  million  bacteria  and  raising  it  progressively  to  5  and  10  billion. 
The  results  were  very  satisfactory  as  a  rule,  but  in  some  cases  there  was 
a  relapse  which  he  found  was  intractable  to  the  subcutaneous  therapy 
but  yielded  promptly  and  permanently  to  the  intravenous  injections. 

If  these  efforts  are  of  no  avail,  make  use  of  topical  measures  and 
give  as  little  medicine  as  possible,  especially  avoiding  opium  on  account 
of  the  danger  of  the  habit. 

In  the  chronic  form  the  use  of  the  irrigation  is  more  valuable  than 
in  the  acute. 

There  is  one  thing  about  the  irrigation  and  the  use  of  all  topical 
measures  to  be  insisted  upon  and  that  is,  if  used  in  the  acute  stage 
assiduously  the  chronicity  of  the  process  may  be  due  to  the  irritation 
these  very  measures  keep  up,  and  a  cessation  of  all  local  treatment  be 
followed  by  rapid  improvement.  Again,  when  these  methods  are  pur- 
sued in  a  chronic  case,  improvement  may  be  seen  up  to  a  certain  point 
and  then  cease  or  the  condition  grow  worse.  Here  again  stop  the  treat- 
ment and  study  the  effect. 

The  irrigation  is  to  be  done  with  the  patient  in  the  dorsal  position 
with  the  hips  elevated  and  on  a  douche-pan,  or  lying  across  the  bed 
on  a  rubber  sheet  so  arranged  as  to  form  a  gutter  for  the  discharge  of 
water. 

Sometimes  the  bowel  is  better  filled  by  putting  the  patient  on  his 
left  side  and  then  turning  him  to  his  right,  so  as  to  seek  the  assistance 
of  gravity  in  following  the  line  of  the  colon. 


DYSENTERY— BACILLARY  AND  AMEBIC  367 

If  the  patient  is  fairly  strong,  the  more  trying  knee-chest  or  elbow 
position  may  be  used. 

The  tube  should  be  long  and  soft,  a  rectal  tube,  a  stomach  siphon 
or  a  large  rubber  catheter  will  answer. 

The  tube  is  warmed,  lubricated  and  passed  carefully  into  the  bowel, 
as  any  roughness  will  cause  a  contraction  and  defeat  the  purpose.  If  it 
meets  with  an  obstruction,  wait  until  a  spasm  ceases  and  then  try  again. 
If  difficulty  is  met  with  let  a  little  water  pass  in  to  distend  the  gut  and 
try  again.  Pass  it  in  4  or  5  inches. 

The  tube  is  then  or  has  previously  been  attached  to  a  Y  tube,  to 
the  other  two  limbs  of  which  are  attached  the  fountain  syringe  and  the 
drainage  tube.  The  bag  contains  for  a  simple  irrigation  plain  water  or 
better  a  physiological  salt  solution,  a  level  teaspoonful  of  salt  to  the 
pint,  at  a  temperature  of  100°  F.  It  should  be  held  about  three  feet 
above  the  level  of  the  patient's  body.  The  water  is  allowed  to  flow  in  and 
out,  by  alternatingly  pinching  the  outflow  tube  and  the  inflow  tube. 
Discomfort  on  the  part  of  the  patient  tells  when  enough  has  been  intro- 
duced at  any  one  time. 

If  irrigation  of  the  lower  part  of  the  intestine  alone  is  aimed  at,  a 
two-way  tube  like  the  Kemp  tube  is  a  great  convenience. 

About  two  quarts  may  be  used  at  a  time;  in  some  cases,  even  more. 

The  irrigation  may  be  followed  by  an  astringent. 

The  best  astringent  is  silver  nitrate.  It  should  be  used  in  in- 
creasing strengths,  1  to  2,000  at  first  and  increasing  up  to  1  in  500  or 
1  in  400  or  300. 

Use  one  or  two  pints.  It  may  be  introduced  through  the  same  syringe 
and  tube.  The  tube  should  be  pinched  to  keep  the  solution  in  contact 
with  the  bowel  a  few  minutes  or  left  in  for  the  patient  to  pass. 

If  salt  solution  is  used  at  first,  it  must  all  be  discharged  or  the  silver 
will  be  neutralized  by  it. 

In  this  case,  if  such  difficulty  is  constantly  met  with,  use  plain  water. 
If  the  solution  of  silver  gives  great  pain  it  is  too  strong  and  may  be 
neutralized  by  salt  solution. 

The  treatment  may  be  tried  daily  in  the  weaker  solutions  and  then 
less  frequently.  Intermit  the  treatment  occasionally  to  let  the  mucous 
membrane  recover  from  any  irritation  by  the  silver  that  might  have 
been  excessive. 

If  success  is  not  achieved  with  the  nitrate,  after  an  intermission  of 
a  few  days,  some  organic  salts  may  be  used,  e.  g.,  protargol  in  a  1-500 
solution.  Some  clinicians  prefer  the  organic  salts  to  the  nitrate. 

The  protracted  cases  are  often  due  to  ulcers  which  will  not  heal 
under  this  milder  application;  hence,  an  effort  should  be  made  by  the 


368  TREATMENT  OF  ACUTE  INFECTIOUS  DISEASES 

aid  of  the  proctoscope  or  sigmoidoscope  to  detect  and  treat  directly 
any  ulcer  within  reach.  Here  strong  silver  in  25  per  cent,  solution 
or  the  stick  may  be  used. 

There  are  two  other  important  matters  to  be  taken  into  consideration 
in  the  treatment  of  chronic  dysentery — namely,  change  in  environment 
and  the  diet. 

In  chronic  dysentery,  particular'y  in  the  tropics,  when  the  laboratory 
findings  fail  to  establish  a  diagnosis  between  bacillary  and  amebic 
dysentery  it  is  worth  while  to  administer  a  few  doses  of  emetin  on  the 
possibilities  of  establishing  a  therapeutic  diagnosis  (see  amebic  dysen- 
tery). 

Change  in  Environment.  What  those  subtle  influences  are  that 
determine  improvement  in  a  new  environment,  seen  in  those  patients 
fighting  to  overcome  a  lingering  infection  of  one  kind  or  another,  defies 
analysis  at  present. 

While  climate,  fresh  air,  sunlight  and  other  physical  conditions  may 
be  appealed  to,  they  are  not  always  sufficient.  The  effect  upon  the 
mind  induced  by  a  change  certainly  has  something  to  do  with  the  re- 
sults. I  recall  a  bitter  struggle  with  dysentery,  occurring  in  a  patient 
attacked  away  from  home,  dragging  out  to  eight  or  ten  weeks  in  whom 
the  home-going,  though  effected  on  a  stretcher,  brought  health  and 
strength  in  a  manner  little  short  of  the  miraculous,  and  such  examples 
every  practitioner  of  medicine  can  recall. 

Diet  in  the  prolonged  or  chronic  cases  is  an  important  problem. 

During  the  progress  of  this  disease  the  patient  loses  much  flesh,  to 
which  the  low  diet  adopted  to  spare  the  inflamed  bowel,  has  been  a 
factor. 

Loss  of  body  substance  in  infectious  diseases  is  due  to  (1)  pyrexia, 
(2)  toxemia,  and  (3)  starvation.  Now,  in  these  prolonged  cases  the 
fever  has  waned  and  the  signs  of  general  toxemia,  other  than  the  residual 
weakness,  have  subsided,  and  because  the  patient  has  still  too  many 
loose  stools  .with  mucus,  he  is  kept  on  the  same  restricted  diet. 

The  diet  is  milk,  perhaps  two  quarts  of  it  with  about  1,280  calories 
and  70  gms.  of  proteid.  Now  how  can  a  man,  whose  daily  needs  are 
well  over  2,000  calories,  make  up  1,000  deficit  out  of  his  own  tissues  day 
after  day  and  still  afford  energy  enough  for  successful  resistance  and 
repair?  The  proposition  is  absurd,  and  I  am  convinced  that  in  a  large 
percentage  of  these  cases  that  drag  along,  starvation  is  at  the  bottom 
of  it. 

I  look  through  dietary  after  dietary  and  see  milk,  cautiously  a  little 
egg  and  still  more  cautiously  a  little  scraped  meat  offered,  and  no  men- 
tion made  of  the  use  to  which  the  carbohydrates  could  be  put.  I  do 


DYSENTERY— BACILLARY  AND  AMEBIC  369 

not  think  we  should  be  alarmed  at  the  addition  of  a  little  sugar  to  the 
milk,  and,  if  we  fear  fermentation,  we  can  add  milk-sugar  which  is  not 
easily  fermentable.  Every  ounce  is  worth  120  calories  and  we  could 
add  three  ounces  to  the  two  quarts  of  milk  without  provoking  trouble 
or  even  distaste. 

The  cereals  should  be  used — barley,  rice,  farina,  bread  and  butter, 
cereal  soups;  eggs  may  be  given,  each  worth  60  to  70  calories.  A  small 
chop  is  easily  digested  and  modern  physiology  emphasizes  how  easily 
proteid  is  digested  and  assimilated  and  there  are  100  calories  more. 

Beef,  mutton,  chicken,  and  potatoes  leave  but  little  residue,  and 
if  the  patient  does  well  on  this  more  liberal  diet,  give  him  some  of  the 
green  vegetables,  purged  at  first — peas,  or  small  stringed  beans — and 
let  us  see  if  they  do  not  improve  rather  than  aggravate  the  condition. 

What'  should  be  emphasized  is  that  the  body  may  suffer  more  from 
the  absence  of  food  than  the  intestine  from  its  presence,  and  that  prac- 
tically all  the  food  above  mentioned  is  absorbed  from  the  small  intestine 
which  is  not  the  seat  of  the  lesion  and  so  does  not  arrive  at  the  point  of 
irritation  at  all;  that  when  the  acuteness  of  the  process  has  subsided, 
one  should  consider  the  dietetic  need  of  the  patient,  and  see  that  he  gets 
it,  at  first  in  food  that  leaves  but  little  residue,  and  then  permitting 
other  foods  little  by  little.  We  are  humiliated  sometimes  to  find  that 
these  chronic  cases  improve  when  first  they  escape  our  hands. 

Prophylaxis.  The  bacillus  seems  to  be  water-borne,  and  so 
when  an  epidemic  occurs  the  same  precautions  should  be  taken  as  in 
that  other  water-borne  infection — typhoid  fever.  Water  should  be 
boiled,  milk  inspected  or  boiled,  green  vegetables  thoroughly  cleaned. 

In  all  epidemics  cooks  and  others  handling  food  should  be  examined 
to  determine  whether  or  no  they  are  carriers  and  no  one  suffering 
from  diarrhea,  even  of  a  mild  type,  should  be  allowed  to  come  in  con- 
tact with  food  supplies. 

In  an  epidemic  all  convalescents  should  be  suspected  of  being  car- 
riers. All  people  handling  foods  should  be  so  suspected.  Precautions 
to  be  taken  by  nurses,  doctors  or  others  about  the  patients  have  been 
detailed.  Toilets,  as  being  possibly  contaminated  with  infected  feces, 
must  be  kept  rigidly  clean  with  antiseptics.  Infection,  too,  may  come 
from  contact,  and  the  stools  should  be  destroyed  and  clothes  and  uten- 
sils, etc.  (see  Typhoid  Fever,  Chap.  XIV),  treated  in  the  same  manner 
as  in  typhoid. 

Especial  care  should  be  taken  by  nurses  handling  infants  lest  the 
infection  be  carried  by  handling  soiled  linen. 

Flies  are  carriers  and  should  be  kept  from  the  sick  room  by  screens, 
from  the  food  supply  by  screens,  and  exterminated  by  every  known 


370  TREATMENT  OF  ACUTE  INFECTIOUS  DISEASES 

means.  All  stools  should  be  disinfected  and  this  is  doubly  imperative 
when  stools  are  disposed  of  in  outhouses  as  is  frequent  in  the  country 
or  in  cesspools,  accessible  to  the  fly. 


Rest. 

In  bed. 


SUMMARY 
Bacillary   Dysentery 


Bed. 

Half  bed;  hospital  type  best. 

Woven  wire  springs. 

Hair  mattress. 

Rubber  sheet. 

Draw  sheet. 

Sheets;  light  blanket;  low  pillow. 

Room. 

Well  ventilated;  shaded  balcony;  adjacent  bathroom. 

Care  of  the  body. 
Bath. 

Castile  soap  and  warm  water  daily. 

Alcohol  rubs,  especially  over  points  of  pressure  in  emaciated  cases. 
Talcum  or  other  drying  powders. 
Mouth. 

Rinse  after  every  feeding;  use  boric  acid  solution  2-4  per  cent, 
strength.    Dobell's  Solution. 

Teeth  brushed  twice  a  day. 

Interstices  of  teeth  freed  from  food  particles.     Use  small  cotton 

swabs  on  wooden  tooth-picks  as  applicators. 
Tongue. 

Soften  coat  with  one-half  strength  peroxide  of  hydrogen. 

Cleanse  with  boric  acid  solution  or  DobelPs. 
Dry  mouth. 

Equal  parts  of  2  per  cent,  boric  acid  solution  and  abolene  flavored 

with  lemon  juice. 

Points  of  pressure — threatened  bed  sores.    Change  of  position;  rub- 
bing; rubber  rings;  air  cushions. 
Exclude  visitors. 

Use  of  bed-pan  imperative.    (Technique,  see  text.) 
Woolen  material  over  abdomen. 

Nurse  should  wear  rubber  gloves  or  disinfect  hands. 

Physician  should  wear  gloves  when  examining  patient  or  disinfect  hands 
thoroughly. 


DYSENTERY— BACILLARY  AND  AMEBIC  371 

Diet 

Boiled  milk,  diluted  1/2  to  1/3  or  1/4  with  plain  water,  barley  water 

or  rice  water. 

Eight  ounces  every  two  hours. 
Next  add  milk  sugar  1/2  ounce  to  1  ounce  to  each  glass  to  increase 

calories. 
If  there  is  gastric  distress,  flatulency,  coated  tongue  or  curds  in  stools, 

skim  the  milk  or  cut  out  sugar  or  both.    If  marked,  stop  all  food 

for  a  time. 
If  milk  is  not  well  borne  use  barley  water,  rice  water,  arrowroot 

water,  egg-albumin,  thin  chicken  broth  (free  from  fat)  mutton 

broth  (free  from  fat).     Gradually  thicken  the  cereal  waters  and 

boil  them  into  the  broths.    Add  milk-sugar  to  the  cereal  waters. 

Add  toast. 

All  food  should  be  given  warm,  not  hot  or  cold. 
When  temperature  is  normal  and  stools  take  on  substance,  add 

boiled  rice,  then  toast,  then  chop,  then  pureed  vegetables  and  then 

normal  diet. 
Water  should  be  given  freely  throughout;  administered  with  the 

chill  taken  off. 

Care  of  the  bowels. 
Preliminary  catharsis. 
Castor  oil  5ss.-i  (15-30  c.c.)  best;  or  salts,  Epsom  preferred,  5ss.-i 

(15-30  Gm.) 

If  there  is  nausea  or  vomiting,  calomel,  gr.  1/4  or  1/10  (0.015-0.006 
Gm.)  at  fifteen  or  ten  minute  intervals  until  gr.  i  to  gr.  iss.  (0.060- 
0.10  Gm.)  be  given  (acts  as  an  antiemetic  as  well  as  a  cathartic). 
Follow  in  two  or  three  hours  by  castor  oil  or  salts,  as  above. 
How  to  disguise  castor  oil.    (See  text.) 

Specific  treatment. 

Serum  best  prepared  from  strain  concerned.  Polyvalent  used  for 
want  of  better.  Dose  40-60  c.c.  with  equal  amounts  of  normal 
saline.  Method  intravenous.  Frequency — repeated  if  necessary 
each  day,  40-60  c.c.  Technique  (see  Pneumonia,  Chap.  IX). 
Polyvalent  80-100  c.c.  has  been  used  subcutaneously. 

Vaccine  therapy  should  be  an  autogenous  vaccine  when  possible.    Me- 
thod— intravenous.    Dosage  small  at  first,  10,000  increasing  30,000; 
50,000;  100,000  up  to  10  million. 
Frequency,  4-day  intervals.    Early  treatment  most  efficacious. 

Empirical  treatment. 
Castor  oil  in  small  doses  frequently  and  in  large  doses  at  intervals. 

9 

OleiRicini 10.00        5    iiss. 

Phenylis  Salicylatis 2 . 50        gr.  xxxvii 

Tr.  Opii  Deodorati 1 .00        m.  xv 

M.  et.  div.  in  capsulas  no.  xv. 


372  TREATMENT  OF  ACUTE  INFECTIOUS  DISEASES 

One  every  two  hours;  with  improvement  every  three  hours;  then 

every  four  hours. 
If  of  mild  grade  leave  out  opium. 
Every  second  day  castor  oil  gss.-i  (15-30  c.c.). 

Saline  treatment. 

Magnesium  sulphate  (Epsom  salt)  or  sodium  sulphate.  (Glauber's 
salt)  5ss.-i  (15^-30  Gm.);  follow  by  3i  (4  Gm.)  doses  every  two 
hours;  then  as  improvement  occurs  three  and  four  hours. 

Symptomatic  treatment. 
Pain — xjol  ic. 

Topical  applications. 

Heat. 

Fomentations.    (Technique,  see  text.) 
Turpentine  stupes.    (Technique,  see  text.) 

Thin  poultices.    (Technique,  see  Pneumonia,  Chap.  IX.) 
Rectal  irrigations  of  plain  water  in  salt  solutions  (3i-0i)  (4  Gm.  to 

500  c.c.)  at  100°  F.  to  105°  F. 
Drugs,  when  severe. 

Morphine  sulphate  hypodermically,  least  quantity  effectual,  gr. 
1/16  to  gr.  1/4  (0.004-0.015  Gm.). 

Tenesmus. 

Warm  rectal  irrigations  as  above  for  pain. 
Suppositories  of  opium,  gr.  ss.  (0.030). 
Or 


Opii  Pulveris gr.   i  (0.065) 

Ext.  Belladonna?  fol gr.  M  (0.015) 

Olii  Theobromatis,  q.  s (gr.  xxx)         (2.00) 

M.  et  fiant  talia  suppositoria  no.  xii. 
S.    Insert  one  as  directed. 

Rectal  injections  of  opium  in  starch  paste. 

Tr.  opii  m.  xv  (1  c.c.)  in  5j-ii  (30-60  c.c.)  starch  mucilage  and 

inject  slowly. 

Morphine  sulphate,  gr.  1/16  (0.004  Gm.)  to  gr.  1/4  (0.015  Gm.)  hypo- 
dermically. 

Benzyl  benzoate  20  per  cent,  alcoholic  solution  10-30  drops  three 
times  a  day. 

Diarrhea. 
Usually  satisfactorily  controlled  by  the  small  doses  of  castor  oil  and 

salol  as  described  above  under  empirical  treatment. 
Bismuth  subnitrate. 

Bismuth  subnitrate,  gr.  xxx  (2  Gm.)  every  two  hours.  Adminis- 
tered in  a  little  water;  a  shake  diffuses  the  powder  throughout 
the  liquid  evenly. 


DYSENTERY— BACILLARY  AND  AMEBIC  373 

Every  second  or  third  day  give  castor  oil  (preferably)  or  salt.  5ss.-i 

(15-30  Gm.). 
Opium. 

As  given  with  castor  oil  and  salol,  as  above,  under  empirical  treat- 
ment, it  is  usually  sufficient.  If  not,  increase  the  opium  or 
give  it  with  the  bismuth. 

1.  Never  use  opium  until  the  bowel  is  emptied  by  oil  or  salts. 

2.  Use  it  in  smallest  quantities  that  are  effectual. 

3.  Do  not  advise  the  patient  of  its  use. 

Severe  cases  with  desiccation  of  tissues,  hypodermoclysis  of  normal 
saline;  intravenous  infusion  of  saline;  push  fluids  by  mouth  if 
possible.  Heat  to  extremities.  Morphine  sulphate  gr.  1/4  (0.015 
Gm.).  Atropine  sulphate,  gr.  1/150  (0.0004  Gm.). 

Collapse. 

Strophanthin,  gr.  1/120  (1/2  mg.)  intravenously  or  digitalis,  gr.  3-5 
(0.20-0.33  Gm.)  intravenously.  Adrenalin  hydrochloride  intra- 
muscularly m.  x-m.  xv  (0.66-1.0  c.c.)  every  15  minutes  for  6  doses 
intravenously  m.  ii  to  iii  into  infusion  tube.  Hypertonic  glucose 
solution  25  per  cent.  (250  c.c.  or  gviii). 

Heart. 
Circulatory  failure,  digitalis.    (See  Pneumonia,  Chap.  IX.) 

Subacute  and  chronic  stages. 

Irrigations. 

Technique.    (See  text.) 
Plain  water  or  salt  solution  first;  then  silver  nitrate,  at  first  1-2,000, 

gradually  increasing  up  to  1-500  or,  stronger,  1-300. 
Use  1  or  2  pints  at  100°  F. 
If  it  causes  pain  neutralize  the  silver  in  the  bowel  by  an  enema 

of  salt  solution  (3i-0i)  (4  Gm.  500  c.c.). 

Frequency;  daily  in  weaker  solution,  less  frequently  with  stronger. 
Intermit  occasionally,  as  irritation  of  astringents  may  be  cause  of 

continued  diarrhea. 
Protargol  1 :500  instead  of  the  silver  nitrate. 

Severe  cases. 

Vaccine  therapy  as  in  the  acute  cases.  Raise  dosage  gradually  if 
necessary  to  5-10  billion  intravenously.  (See  text.) 

Ulcers. 

Often  the  cause  of  protracted  cases.  Use  protoscope  or  sigmoidoscope 
to  detect  ulcer  and  apply  medication.  Apply  25  per  cent,  solution 
of  silver  nitrate  or  the  silver  stick.  In  cases  of  doubtful  etiology 
emetine  may  be  used  to  establish  therapeutic  diagnosis.  (See 
Amebic  Dysentery.) 

Change  of  environment. 


374  TREATMENT  OF  ACUTE  INFECTIOUS  DISEASES 

Diet. 

Increased  to  meet  caloric  demands.  (See  Diet  in  Acute  Infectious 
Diseases,  Chap.  II.) 

If  on  milk  add  milk  sugar  5ss.-i  (15-30  Gm.)  to  each  glass  (gviii) 
(240  c.c.),  and  then  cereals,  barley,  farina,  then  rice,  bread  and 
butter,  cereal  soups,  then  mutton  and  chicken  broth  with  rice, 
barley,  arrowroot,  or  flour  to  thicken;  then  eggs,  chop,  chicken, 
potatoes,  peas  and  beans  (at  first  pureed)  and  even  a  more  liberal 
diet. 

Prophylaxis. 

Bacillus  seems  to  be  water-borne. 

Take  same  precautions  in  an  epidemic  as  in  a  typhoid  epidemic. 

Boil  water. 

Drink  only  " inspected"  or  boiled  milk. 

Thoroughly  cleanse  all  green  vegetables  or  exclude  them  from  diet. 

Carriers  should  be  detected  and  not  allowed  to  handle  food  supplies. 

Suspect  convalescents  as  carriers. 

Disinfect  stools.    (See  Typhoid  Fever,  Chap.  XIV.) 

Disinfect  articles.    (See  Typhoid  Fever,  Chap.  XIV.) 

Disinfect  hands  after  handling  patients  and  excretions. 

Screen  room  from  flies. 

Screen  latrines,  outhouses  and  stools  from  flies. 

Screen  food  supply  from  flies. 

AMEBIC   DYSENTERY 

The  clinical  course  of  the  two  types  of  dysentery,  bacillary  and 
amebic,  show  much  in  common;  but  the  former  is  usually  more  abrupt 
hi  onset,  runs  a  more  acute  course  and  is  accompanied  by  a  higher  fever 
and  is  of  briefer  duration,  while  in  the  latter  often  the  acute  attack  is 
preceded  by  relapsing  diarrhea  and  the  locality  in  which  it  was  con- 
tracted (tropical  and  sub-tropical  countries)  and  its  prolonged  course 
makes  the  diagnosis  of  amebic  dysentery  more  than  probable  and  the 
hepatitis  makes  it  certain;  still,  and,  especially,  in  temperate  zones, 
only  the  recovery  of  the  specific  organisms  from  the  stool  can  make  the 
diagnosis  certain  in  the  overwhelming  majority  of  cases. 

The  specific  organism  is  the  Entamoeba  histolytica. 

There  are  other  entamcebse,  for  a  long  time  undifferentiated  from 
histolytica  and  so  credited  with  causation  of  the  disease. 

They  are  the  entamceba  coli,  a  parasitic  organism  and  a  non-par- 
sitic  group  called  the  Umax,  and  as  these  occur  in  the  stools  of  a  goodly 
percentage  of  normal  men  and  so  in  the  stools  of  many  cases  of  bacillary 
dysentery,  it  is  a  matter  of  importance  to  differentiate  them;  the  more 
so  as  the  treatment  most  efficacious  in  amebic  dysentery  has  no  effect 
on  the  progress  of  bacillary  dysentery,  and,  vice  versa,  the  treatment 


DYSENTERY— BACILLARY  AND  AMEBIC  375 

described  for  bacillary  dysentery  does  not  affect  the  Entamoeba  his- 
tolytica  at  all. 

When,  however,  this  differentiation  by  finding  an  entamceba  and 
identifying  it  is  impossible  one  must  rely  on  the  criteria  mentioned  and 
when  in  doubt  give  the  patient  the  benefit  of  the  doubt  and  direct  the 
treatment  as  in  amebic  dysentery;  as  the  emetin  will  do  no  harm  if  no 
good. 

Moreover,  I  do  not  know  any  reason  why  the  empiric  treatment  given 
under  bacillary  dysentery  should  not  be  combined  with  the  emetin 
treatment  in  a  doubtful  case. 

The  pathology  of  amebic  dysentery  is  an  invasion  of  the  mucous 
membrane  of  the  large  intestine,  rarely  to  be  found  above  the  ileocsecal 
valve,  in  mild  cases  confined  to  the  neighborhood  of  the  caecum,  but 
in  severe  cases  involving  the  whole  large  intestine.  The  organisms 
burrow  through  the  mucosa,  in  the  submucosa  cause  a  necrosis  under- 
mining the  mucosa,  and  the  lesion  is  accompanied  by  proliferative 
changes.  Sometimes  the  muscular  coat  is  invaded  and  rarely  the  intes- 
tine is  perforated.  Thrombi  form  in  the  portal  vessels,  cutting  off  the 
blood  supply  to  the  mucosa,  thus  giving  rise  to  ulcers  and  furnishing 
emboli  to  be  carried  to  the  liver,  setting  up  abscesses  in  that  organ.  The 
appendix  is  involved  in  a  small  per  cent,  of  the  cases. 

Symptomatology.  Most  cases  begin  insidiously  with  a  history 
of  recurring  abdominal  pains  and  diarrhea.  The  stools  are  pasty  and  of 
moderate  number,  there  is  no  fever,  but  a  loss  of  strength  and  secondary 
anemia. 

The  blood  shows  a  moderate  leucocytosis  with  an  increase  in  large 
mononuclears.  Decrease  of  mononuclears  looks  toward  a  cure 
(Stitt) .  In  the  lesser  number  of  cases  the  onset  is  abrupt,  the  stools  are 
thinner,  brown  and  greenish  and  may  contain  blood  and  mucus  and  be 
accompanied  by  severe  griping.  There  is  a  febrile  reaction  in  these 
cases,  but  not  as  high  as  in  the  bacillary  form  and  without  the  striking 
evidences  of  the  toxemia  of  the  latter. 

All  the  rules  laid  down  for  the  conservation  of  the  patient's  forces 
and  for  his  comfort  obtain  in  the  one  form  of  dysentery  as  in  the  other. 

For  the  accomplishment  of  rest,  the  choice  and  preparation  of 
the  bed  and  the  room,  the  care  of  the  body  in  all  its  details 
and  the  diet  the  reader  is  referred  to  the  first  section  of  this  chapter, 
Bacillary  Dysentery. 

As  regards  the  diet,  however,  the  severity  and  the  prolonged  course 
of  amebic  dysentery  make  the  plea  for  sufficiency  more  emphatic,  so 
that  with  boiling  of  milk  or  elimination  of  it  when  not  well  borne,  the 
rules  for  diet  laid  down  under  Typhoid  Fever  (see  Chap.  XIV)  should 


376  TREATMENT  OF  ACUTE  INFECTIOUS  DISEASES 

be  a  good  guide.  During  the  acute  stage,  however,  a  fluid  diet  is  indi- 
cated and  such  as  is  laid  down  under  bacillary  dysentery. 

The  care  of  the  bowels  and  the  importance  of  the  preliminary 
catharsis  obtain  in  the  one  as  in  the  other  with  equal  force. 

As  amoebae  are  often  situated  high  in  the  bowel,  they  may  not  be  found 
in  the  early  stools.  It  becomes  desirable  to  dislodge  them  with  a  saline 
purge  and  this  is  to  be  preferred  to  castor  oil;  for  the  oil  as  an  initial 
purge  makes  the  examination  difficult.  Of  course,  it  will  be  remembered 
that  flakes 'of  blood  and  mucus  are  the  best  materials  to  afford  the 
amoebae  and  that  it  must  be  examined  on  a  warm  stage  within  a  few 
minutes  to  determine  the  important  diagnostic  point  of  active  motility. 
The  character  of  the  cysts  are  important,  too;  for  the  entamceba  coli 
contains  eight  nuclei  while  the  histolytica  has  not  more  than  four. 

Treatment.  Very  recently  a  treatment  has  come  into  vogue 
that  promises  to  be  as  nearly  specific  in  this  disease  as  quinine  is  in 
malaria  and  yet  it  is  the  offspring  of  an  older,  I  might  say  "traditional" 
treatment  in  some  parts  of  the  world.  This  older  treatment  rested  on 
the  use  of  ipecac  and  the  more  recent  on  one  of  its  active  principles, 
emetine. 

Ipecac  had  impressed  many  men  practicing  in  India  and  else- 
where in  the  tropics  as  without  a  peer  in  its  curative  effects  in  Tropical 
Dysentery  while  others  found  it  uncertain  or  disappointing.  We  know 
now  that  this  discrepancy  was  due  to  the  varying  amounts  of  emetin  in 
the  ipecac  used,  as  well,  perhaps,  as  to  the  difficulties  in  assuring  a  suffi- 
cient absorption  of  this  drug  so  actively  emetic. 

Within  a  very  few  years  there  has  been  a  revival  in  the  ipecac  treat- 
ment of  dysentery  and  the  results  reported  were  encouraging.  The  drug 
was  given  in  pill  form  coated  with  phenyl  salicylate  (salol)  to  make  it 
insoluble  in  the  stomach.  The  instructions  of  Brown  and  Zeiler  for  its 
use  are  as  follows:  Use  a  salol  coating  1/16  inch  for  the  pills  (thicker 
coating  may  make  it  too  resistant  and  the  pill  passes  in  the  stool  intact; 
thinner  coating  disintegrates  in  the  stomach). 

Ipecac  derived  from  different  sources  contains  varying  amounts  of 
emetine.  The  Brazilian  variety  is  said  to  have  a  very  high  content. 

They  begin  with  60-80  grains  (4-5.30  Gm.)  taken  at  bed-time  and 
decrease  the  dose  5  grains  (0.30  Gm.)  a  day  until  a  dose  of  10  grains 
(0.60  Gm.)  is  reached. 

The  patient  should  be  at  rest  in  bed  and  no  solid  food  or  milk  be 
given  for  at  least  six  hours  previous.  No  opiate,  they  say,  is  necessary. 

The  action  of  emetine  is  so  much  more  certain  and  satisfactory  that 
the  only  justification  for  the  use  of  ipecac  is  the  inability  to  get  emetine. 

Emetine  Treatment.     Of  the  active  principles  of  ipecac  emetine 


DYSENTERY-BACILLARY  AND  AMEBIC  377 

is  found  to  be  the  one,  and  only  one,  that  is  amebicidal;  while  that 
action  that  gave  to  it  its  name,  i.  e.,  the  emetic,  does  not  belong  to  it 
at  all,  but  to  another  active  principle,  cephaelin. 

The  credit  for  the  use  of  emetine  in  amebic  dysentery  is  due  to  Rogers, 
an  English  physician. 

While  one  could  wish  a  larger  body  of  statistics  to  justify  such  un- 
qualified praise  as  is  bestowed  on  this  treatment,  still  such  results  as  are 
accruing  to  its  usage  urge  us  to  unhesitatingly  recommend  it. 

Amid  the  gropings  after  the  best  dosage  and  intervals  of  adminis- 
trations, I  shall  choose  Vedder's  as  at  present  a  most  satisfactory  guide. 

One  may  use  either  of  the  two  salts  of  emetine,  the  hydrobromide 
or  the  hydrochloride,  but  the  latter  is  the  more  soluble  and  so  preferable 
for  hypodermic  use. 

The  dose  is  gr.  1/3  (0.020  Gm.),  intramuscularly,  three  times  a  day 
for  ten  days. 

If  at  the  end  of  this  time  the  case  seems  clinically  cured,  the  treatment 
is  discontinued.  If  not  increase  the  dose. 

The  cure  is  very  rapid,  often  within  the  week,  affording  a  striking 
contrast  to  the  prolonged  course  of  the  disease  under  the  old  therapeusis. 
The  stools  in  a  day  or  two  change  in  consistency  and  the  amoebae  quickly 
disappear  in  the  favorable  cases. 

There  is  no  vomiting  or  discomfort  with  this  dose  of  the  drug.  Among 
the  American  Expeditionary  forces  larger  doses  were  used,  the  rule  being 
to  give  1/2  grain  (0.030  Gm.)  of  emetine  hydrochloride  twice  a  day  for 
6  or  12  days,  the  length  of  administration  being  determined  more  or  less 
by  the  gravity  of  the  disease.  If  vegetative  forms  persisted,  the  treat- 
ment was  repeated  after  an  interval.  If  cysts  were  found  in  convales- 
cence and  in  the  case  of  chronic  carriers  emetine  bismuth  iodide  was 
given  in  doses  of  3  to  4  grains  (0.  2-0.26  Gm.)  up  to  36  to  40  grains  (2.30 
to  2.60  Gm.)  total. 

Much  the  same  rule  was  observed  in  the  treatment  of  the  English 
troops  in  the  Mediterranean  during  the  war.  They  were  given  hypoder- 
mically  1  grain  of  emetine  daily  for  10  days.  Sometimes  the  dose  was 
divided  into  1/2  grain  morning  and  night. 

Sellards,  discussing  the  subject  in  Medical  Clinics  of  North  America, 
Jan.  '18,  advises  even  more  liberal  administration,  namely,  1  grain  of 
hydrochloride  of  emetine  (0.060  Gm.)  morning  and  night  for  one  or  two 
days  and  then  one  grain  (0.06  Gm.)  at  night  for  12  to  14  days,  then  after 
an  interval  of  two  to  four  weeks  as  a  matter  of  precaution  give  a  second 
course  of  1  grain  (0.06  Gm.)  daily  for  two  weeks.  This  is  given  into  the 
muscle. 

In  view  of  the  late  development,  months  or  years,  of  hepatic  abscess, 


378  TREATMENT  OF  ACUTE  INFECTIOUS  DISEASES 

Stitt  advises  giving  a  grain  of  emetine  on  two  or  three  successive  days 
each  month  following  the  acute  attack  as  a  prophylactic  measure. 

Bethea's  Method.  Bethea  calls  attention  to  the  four  factors  to  be 
considered  in  treatment;  namely  (1)  the  amoebae  in  the  intestinal  wall; 
(2)  the  amoebae  in  the  bowel  content,  crevices,  etc.;  (3)  mixed  infection; 
(4)  ulceration.  The  first  are  reached  by  the  blood  stream  and  the  most 
suitable  agent  for  destruction  is  emetine  hydrochloride,  which  he  gives  in 
half  grain  doses  for  an  adult  deep  into  a  muscle,  preferably  the  gluteal. 
This  dose  is  repeated  daily  for  24  days  and  then  two  or  three  a  week 
for  several  weeks. 

The  amcebse  in  the  bowel  content  he  thinks  are  best  reached  by  the 
use  of  ipecac  in  pill  form  and  is  begun  only  after  the  acute  symptoms 
have  subsided,  usually  in  one  to  three  days.  His  prescription  calls  for 
pills  and  is  as  follows : 

3 

Ipecacuanhse  Pulv gr.  ccl        (16  Gm.) 

Phenylis  Salicylatis q.  s.          (q.s.) 

Ft.  pil.  ent.  no.  L. 

M.  et  S.  Ten  (10)  at  night  as  directed. 

Ten  such  pills  are  given  on  the  first,  second,  third,  fifth,  eighth,  twelfth, 
etc.,  nights. 

Vomiting  may  occur  in  this  treatment. 

If  the  coating  of  the  salol  is  too  thick  the  pills  may  pass  through  the 
intestine  unchanged.  It  may  be  necessary  to  use  bromide  before  taking 
the  pills.  In  some  instances  the  ipecac  seems  to  provoke  a  rapid  peri- 
stalsis. To  obviate  nausea  and  quiet  peristalsis  he  used  the  following 
prescription : 

B 

Sodii  Bromidi 3i  (4) 

Tr.  Opii  Deod f3i  (4) 

Aquae  Menth.  Pip.  q.  s.  ad fgiv        (120) 

M.  et  S.    One  (1)  tablespoonful  2  hours  before  taking  pills. 

If  nausea  does  occur  the  ice  bag  and  cold  water  applied  to  the  abdo- 
men, Seltzer,  ginger  ale,  and  other  effervescent  drinks  are  used. 

Colon  irrigations  of  quinine  hydrochloride  1:1000  to  1:500  about  a 
half  a  gallon  an  hour  or  two  before  taking  the  pills. 

Ulcers  and  mixed  infections  are  treated  as  in  bacillary  dysentery. 

The  most  convincing  proof  of  the  specific  effect  of  the  drug  upon 
the  entamceba  histolytica  is  the  results  in  the  cases  complicated  by 
Hepatitis,  hepatic  abscess.  Abscesses  occur  in  the  liver  in  about 
20  per  cent,  of  the  cases.  In  a  certain  small  percentage  of  the  cases 


DYSENTERY— BACILLARY  AND  AMEBIC  379 

10  per  cent,  to  40  per  cent.,  no  history  of  dysentery  is  obtainable,  but 
as  the  abscess  may  occur  years  after  an  attack  which  may  have  been 
mild  and  as  autopsies  show  the  old  lesions  of  dysentery  in  cases  when  no 
history  was  obtainable  one  can  understand  this  hiatus  in  the  history. 

Some  35-40  per  cent,  are  double  or  multiple  and  they  vary  in  size  from 
very  small  foci  of  pus  to  such  as  contain  a  pint  or  a  quart. 

Untreated  abscesses  show  a  tendency  to  rupture,  most  commonly  into 
the  lung  and  pleural  cavity,  next  into  the  peritoneal  cavity,  into  stomach 
and  intestines,  rarely  into  vena  cava,  pericardium,  kidney;  that  is  into 
any  structures  adjacent  to  the  liver  surfaces. 

The  symptoms  are  a  low  grade  irregular  fever,  and  when  this  follows 
on  a  dysentery  the  diagnosis  is  fairly  certain;  often  with  sweating, 
tenderness  or  pain  over  the  liver,  an  irregular  enlargement  of  the  liver, 
usually  of  the  right  lobe,  without  splenic  enlargement;  pain  referred 
to  the  right  shoulder,  if  the  abscess  is  near  the  upper  surface  of  the  liver; 
to  the  appendix,  if  near  the  under  surface;  or  to  the  gastric  region,  if 
the  left  lobe  (Stitt).  When  implicating  the  pleura  the  cough,  sweat, 
fever,  anemia  and  wasting  certainly  suggests  tuberculosis. 

Jaundice  is  rare  in  contrast  to  suppurative  cholangitis  for  which  it 
may  be  mistaken.  Aspiration  of  an  abscess  withdraws  a  dark  chocolate 
colored  pus.  This  pus  rarely  contains  the  amoebae,  which  are  to  be  found 
in  the  necrotic  walls  and  appear  after  two  or  three  days  of  drainage. 

Of  sixteen  cases  reported  100  per  cent,  were  cured.  Remembering 
the  mortality  of  these  cases  set  by  different  observers  at  figures  varying 
from  30  per  cent,  to  80  per  cent,  and  that  the  best  surgical  results  can- 
not boast  of  better  figures  than  25  per  cent,  mortality,  one  does  not 
wonder  at  the  enthusiasm  that  led  Vedder  to  say  that  "any  amebic 
patient  who  is  not  moribund  can  be  cured  by  emetine."  Such  results 
sound  almost  too  good  to  be  true  and  such  successful  treatment  assumes 
an  appreciation  of  the  presuppurative  stage  of  the  hepatitis  and  its 
prompt  treatment. 

The  dose  of  emetine  in  liver  abscess  and  mode  of  administration 
and  intervals  is  the  same  as  in  the  uncomplicated  dysentery.  If  pus 
has  already  been  formed  it  must  be  evacuated,  and  the  cavity  drained; 
but  as  the  cause  for  suppuration  is  removed  in  the  elimination  of  the 
amoebae  under  emetine  the  discharge  ceases,  the  wound  heals  and  the 
cure  is  effected. 

One  of  two  methods  are  in  vogue  in  the  surgical  treatment  of  hepatic 
abscesses:  (1)  Drainage  by  trochar  and  cannula.  (2)  Open  incision. 
Quoting  Stitt  briefly  (Diagnostics  and  Treatment  of  Tropical  Diseases'). 
The  procedure  in  (i)  is  as  follows:  "Under  a  local  or  general  anaesthetic 
aspiration  is  made  over  obvious  site  of  abscess,  or  this  not  in  evidence, 


380  TREATMENT  OF  ACUTE  INFECTIOUS  DISEASES 

in  the  8th  or  9th  intercostal  spaces  in  right  anterior  axillary  line,  pass- 
ing backward,  inward  and  slightly  upward.  The  needle  should  have  a 
bore  of  1/8  inch  and  should  be  3  1/2  inches  long.  A  larger  needle  en- 
dangers the  vena  cava.  If  necessary,  mutiple  punctures  may  be  made. 
If  pus  is  obtained  the  needle  is  left  in  situ  and  through  a  small  skin  in- 
cision along  the  course  of  the  needle  is  passed  a  4  to  5  inch-  trochar  and 
cannula  with  a  bore  of  3/8  inch.  The  trochar  is  withdrawn,  a  fenes- 
trated  rubber  drain  passed  through  the  cannula,  which  is  in  turn  with- 
drawn, the  tube  transfixed  with  a  safety  pin  to  anchor  the  tube  and 
dressing  applied." 

Some  men  irrigate  the  cavity  with  1-1000  emetine  hydrochloride 
solution  or  1-1000  quinine  solution.  For  the  open  incision  one  should 
consult  authorities  on  surgical  technique,  which  is  out  of  the  province 
of  this  book. 

In  cases  clinically  cured  the  amoebae  do  not  always  disappear  from 
the  stools;  that  is,  the  patients  become  " carriers"  and  as  such  are  a 
menace  to  the  community. 

In  some  of  these  cases  there  occur,  and  some  say,  as  a  rule,  even  after 
months  or  years,  relapses. 

Relapses.  A  relapse  is  to  be  treated  as  the  original  attack 
by  a  repetition  of  the  series  of  emetine.  Such  treatment,  unfortunately 
is  not  always  successful.  Indeed,  emetine  has  its  decided  limitations. 
Sellards  says  that  it  is  almost  without  action  in  the  extremely  acute, 
fulminating  cases,  even  when  given  into  the  vein  in  2  grain  doses  and 
also  in  the  extremely  chronic. 

Explanation  for  this  is  not  yet  forthcoming,  but  he  believes  death  in 
the  acute  cases  is  due  to  a  secondary  bateriemia,  the  amcebiasis  per  se 
being  rarely  fatal. 

There  is  a  limit  to  the  dosage  too.  The  toxic  dose  is  set  by  Rogers  as 
15  grains  in  an  adult  man  and  as  it  has  a  cumulative  action  the  inter- 
missions after  10-14  days  dosage  usually  observed  is  logical.  Some- 
times disagreeable  results  follow  the  first  dose  of  the  drug  in  people 
presumably  susceptible.  There  are  usually  hyperasthesise  and  parses- 
thesise. 

Emetine  is  irritating  and  must  be  given  into  the  muscle  and  every 
aseptic  precaution  must  be  observed  to  prevent  infection.  In  obstinate 
cases  one  seeks  adjuvants  to  the  emetine  in  some  other  amebacide. 

Ipecac  given  by  the  bowel  at  the  same  time  as  emetine  intra- 
muscularly. The  object  is  to  bring  the  emetine  into  contact  with 
amcebse  in  necrotic  areas  in  the  colon  that  cannot  be  reached  by  the 
blood  stream. 

Lawson  advises  its  use  in  the  following  manner:    60-120  grains  of 


DYSENTERY-BACILLARY  AND  AMEBIC  381 

powdered  ipecac  is  put  into  24  ounces  (720  c.c.)  water;  this  is  kept  hot, 
but  not  boiled,  for  an  hour.  This  whole  amount,  while  warm  is  intro- 
duced into  the  bowel  and  retained  as  long  as  possible.  It  should  be 
introduced  slowly  with  the  patient  lying  on  the  left  side.  This  is  re- 
peated daily. 

Ipecac  may  be  taken  by  the  mouth  while  emetine  is  given 
intramuscularly,  hoping  thereby  to  get  a  local  effect  as  well  as  by  the 
blood  stream.  It  may  be  given  as  salol  (phenyl  salicylate)  coated  pills 
or  as  emetine  bismuth  iodide.  The  doses  of  both  ipecac  and  emetine 
should  be  somewhat  lowered  when  given  thus  together. 

Quinine  may  be  given  as  high  enemata,  using  1-5000  up  to 
1-1000  solution  of  a  soluble  salt,  such  as  dihydrochloride  and  urea  or 
bisulphate  in  amounts  of  one  to  two  quarts  (liters.) 

Ed  sail  has  called  attention  to  the  rarity  of  relapses  in  cases  of  hepatic 
abscesses. 


OTHER  DRUGS  THAN  EMETINE 

Quinine  Treatment.  Brook  of  the  Army  reported  on  most  gratify- 
ing results  following  the  use  of  quinine  given  by  mouth. 

He  called  attention  to  the  known  amebicidal  effects  of  a  solution  of 
quinine  and  attributed  its  failure  when  given  by  the  rectum  to  its  in- 
ability to  reach  the  organism  in  the  tissues. 

His  dosage  is  gr.  xxii-xxx  (1.5-2  Gm.)  a  day  for  six  days. 

He  stops  a  week  and  then  repeats  the  series;  especially  in  chronic 
cases. 

He  believes  that  the  special  field  of  quinine  is  in  chronic  cases  and 
those  that  relapse  after  emetine.  He,  too,  believes  that  emetine  is  a 
specific  in  acute  cases,  but  not  as  certain  in  the  chronic,  while  in  all 
cases  he  believes  quinine  in  2  Gm.  doses  (gr.  xxx)  per  day  to  be  as  effi- 
cient as  ipecac. 

Benzyl  Benzoate.  Haughwout  and  his  co-workers  in  the  Philip- 
pines advise  the  use  of  benzyl  benzoate  in  this  form  of  dysentery,  either 
alone  or  in  combination  with  emetine. 

They  used  a  20  per  cent,  alcoholic  solution  of  the  drug  in  doses  of  10 
to  30  drops,  three  times  a  day  after  eating.  Their  experience  was  en- 
tirely limited  to  acute  cases,  in  which  they  got  satisfactory  results 
with  no  ill  effects. 

Subjective  symptoms  rapidly  improved  as  the  sedative  effect  of  the 
drug  on  smooth  muscle  might  lead  us  to  anticipate;  and  in  so  far  re- 
places opium;  but  more  than  that  the  amosbse  disappeared  from  the  stool 
as  promptly.  Why  this  should  occur  is  open  to  speculation. 


382  TREATMENT  OF  ACUTE  INFECTIOUS  DISEASES 

They  look  upon  it  as  valuable  adjuvant  to  ipecac  or  emetine,  which 
they  use  much  as  above  described.  They  further  advise  benzyl  ben- 
zoate  as  a  sedative  in  the  bacillary  form.  In  very  acute  dysenteries 
before  diagnosis  is  established  they  give*  serum  to  secure  what  ad- 
vantage is  possible,  if  the  case  should  prove  to  be  bacillary. 

Bitter  Bush  (Chaparro  Amargosa)  a  shrub  from  Mexico  and  Texas 
used  as  an  infusion  of  the  dried  leaves  and  stems  to  about  the  color 
of  weak  tea,  given  liberally  by  mouth  and  rectum  has  been  used  with 
rather  astonishing  results  according  to  some  observers  even  in  cases 
resistant  to  emetine.  Infusion  is  made  from  the  roots,  branches,  foliage 
and  fruit  of  the  chaparro  amargosa  by  boiling  for  30-60  minutes.  The 
weight  used  varies  with  the  season  and  dryness  of  the  plant.  The  color 
of  the  infusion  should  be  that  of  moderately  weak  tea. 

Routine  of  the  treatment  is  as  follows:  The  patient  is  put  to  bed,  if 
possible;  given  a  liquid  or  semi-solid  diet  the  day  before  and  during  the 
treatment.  Three  or  four  hours  before  treatment  is  begun  magnesium 
sulphate  §i  (30  Gm.)  is  given  and  it  is  repeated  every  two  or  three  days. 

A  half  hour  before  each  meal  and  at  bed  time  six  to  eight  ounces  of  the 
infusion  of  bitter  bush  is  given  by  mouth.  An  enema  of  the  infusion  of 
bitter  bush  (500  to  2000  c.c.)  is  given  in  the  knee  chest  position  twice  a 
day.  This  position  should  be  held  for  five  to  ten  minutes  and  the  enema 
retained  as  long  as  possible. 

If  there  is  any  fecal  matter  in  the  rectum  the  enema  should  be  preceded 
by  an  irrigation. 

Bismuth  subnitrate  in  5i  doses  3  to  4  times  a  day  has  been 
advised. 

Protargol  1-500  has  been  used  by  the  bowel.  Saline  irrigation 
to  keep  the  bowels  as  free  as  possible  from  necrotic  material  is  advised  by 
some  workers. 

Complications  and  Sequelae  except  the  hepatic  abscesses  (dis- 
cussed above),  are  rare.  Primary  abscesses  have  been  known  to  occur 
elsewhere  than  the  liver;  for  example,  in  the  spleen  and  the  brain,  skin 
and  muscles.  In  the  brain  the  symptoms  are  those  of  brain  tumor. 
Meningitis  does  not  occur. 

A  rare  sequel  to  amebic  dysentery  is  a  polyarthritis.  Considering  how 
often  secondary  bacterial  invasion  occurs  in  this  form  of  dysentery,  it 
seems  fair  to  conclude  that  these  are  the  cause  of  the  arthritis  rather  than 
amoebae.  (For  treatment  see  Rheumatism,  Chap.  IV.) 

Carriers.  If  emetine  is  so  decided  in  its  toxic  effect  on  the  enta- 
mcebse  it  would  seem  logical  to  bring  it  into  direct  contact  with  the 
organisms  in  the  stools  in  the  case  of  carriers,  but  emetine  in  any  dilution 
has  proven  too  irritating  to  the  intestine  to  make  its  use  feasible. 


DYSENTERY— BACILLARY  AND  AMEBIC  383 

High  irrigations  of  silver  nitrate  and  of  quinine  have  been  found 
efficient. 

Silver  nitrate  may  be  used  as  in  bacillary  dysentery  in  strength  of 
1  to  2,000  up  to  1  to  500  or  even  300. 

Quinine  solutions,  on  which  the  hopes  of  the  therapeutists  were  once 
placed,  while  unable  to  reach  the  amoebae  in  the  tissues,  can  reach  them 
and  kill  them  in  the  stools  and  afford  a  means  of  attacking  the  carrier 
cases. 

The  solution  should  be  from  1  to  2,000,  up  to  1  to  500. 

Oil  of  chenopodium  in  doses  of  16  minims  (1  c.c.)  at  three- 
hour  intervals  has  been  recommended.  It  should  be  preceded  by  a  purge 
of  magnesium  sulphate,  and  followed  by  castor  oil. 

Surgery.  Since  the  introduction  of  emetine  the  surgical  procedure 
on  the  liver  is  a  matter  of  far  less  magnitude,  while  the  operations  on  the 
bowel,  such  as  appendicostomy  for  colonic  irrigations  are  less  commonly 
indicated. 

In  the  most  intractible  cases  the  appendicostomy  is  the  operation 
of  choice.  This  is  followed  with  irrigations  of  various  kinds,  normal 
saline,  1  per  cent,  bicarbonate  of  soda  or  boracic  acid  for  cleansing  pur- 
poses and  then  by  1  to  10,000  permanganate  of  potash,  protargol  1-500, 
silver  nitrate  1-5000  to  1-2000,  quinine  solutions  as  above. 

Prophylaxis.  With  the  knowledge  that  infection  comes  through 
the  ingesta,  boiling  of  all  water  and  cooking  of  all  foods,  together  with 
disinfection  of  the  excreta  and  scrupulous  cleanliness  in  the  handling  of 
the  same  constitutes  prophylaxis.  Persistent  effort  must  be  made  by 
screening  to  keep  flies  from  contact  with  stools  on  the  one  hand  and 
food  on  the  other.  War  of  extermination  should  be  made  on  the  fly. 
Detection  and  treatment  of  the  carrier  (see  above)  constitutes  no  small 
part  of  prophylaxis.  It  is  the  carrier  and  convalescent  that  scatter 
encysted  amosbae  broadcast.  The  number  of  these  organisms  in  a 
stool  is  extraordinary.  In  the  study  of  cases  among  the  troops  it  was 
estimated  that  330,000  to  45,000,000  were  discharged  daily  by  carriers. 

SUMMARY 
Amebic  Dysentery 
Rest. 


Bed. 
Room. 


(See 

Bacillary 

Dysentery  above.) 


Care  of  the  body. 

Diet. 

(See  Bacillary  Dysentery  and  in  prolonged  cases  see  Typhoid  Fever.) 


384  TREATMENT  OF  ACUTE  INFECTIOUS  DISEASES 

Care  of  the  bowels. 

Preliminary  catharsis. 

Use  salines  to  dislodge  amoebae  high  in  bowel,  thus  facilitating  examina- 
tion of  stools  for  amcebse.  Castor  oil  makes  examination  difficult. 
Epsom  salt  is  the  best,  gss.  to  gi  (15  to  30  Gm.)  in  a  glass  of  water. 

Specific  treatment. 

Emetine  hydrochloride  (or  hydrobromide). 
Dose,  gr.  1/3  (0.20  Gm.)  three  times  a  day  for  ten  days. 
Mode  of  administration,  intramuscularly. 

If  at  the  end  of  this  time  the  case  seems  clinically  cured  stop  treat- 
ment. 

If  at  the  end  of  this  time  the  case  does  not  seem  clinically  cured, 

increase  the  dose  to  gr.  }/%  (0.030  Gm.).    (Vedder.) 
When  emetine  is  not  procurable  use  the  ipecac  treatment. 

Dose  60  to  80  grains  (4-5.30  Gm.)  a  day,  taken  in  single  dose  at 

bed-time  and  decrease  the  dose  gr.  v  (0.33  Gm.)  each  day  until  a 

dose  of  gr.  x  (0.66  Gm.)  is  reached. 
Mode  of  administration,  by  mouth  in  gr.  v  (0.33  Gm.),  pills  coated 

with  phenyl  salicylate  (salol),  1/16  inch  thick. 
Patient  at  rest  in  bed  and  no  solid  food  or  milk  given  for  at  least  six 

hours  previously  (no  opiate  necessary). 
Or, 
Emetine  hydrochloride,  }/£  grain  (0.030  Gm.)  intramuscularly  twice 

a  day  for  6  to  12  days. 
If  cysts  persist  and  in  chronic  carriers,  use: 
Emetine  bismuth  iodide — dose,  3  to  4  grains  (0.2-0.26  Gm.)  up  to  36  to 

40  grains  (2.30-2.60  Gm.)  total.   (American  Expeditionary  Forces.) 
Or, 
Emetine  hydrochloride  intramuscularly,  gr.  i  (0.060  Gm.)  daily  for 

10  days  or  J^  doses  morning  and  night.    (English  troops  in  Mediter- 
ranean.) 
Or, 
Emetine  hydrochloride,  gr.  i  (0.060  Gm.)  intramuscularly  morning 

and  night  for  two  days,  then  gr.  i  (0.060  Gm.)  at  night  for  12  to  14 

days  then  stop  for  2  to  4  weeks  and  resume  gr.  i  (0.060  Gm.)  daily 

for  two  weeks.    (Sellards.) 
To  prevent  late  hepatic  abscess  give  emetine  hydrochloride,  gr.  i 

intramuscularly  for  2  or  3  days  in  succession  each  month.    (Stitt.) 
Or, 
To  get  amcebse  in  intestinal  wall — Emetine  Hydrochloride,  gr.  ss. 

(0.030  Gm.)  intramuscularly  daily  for  24  days,  then  2  or  3  injections 

a  week  for  several  weeks. 
And, 
To  get  amoebae  in  bowel  content — Ipecac. 

9 

Ipecacuanhas  Pulv gr.    ccl        (16) 

Phenylis  Salicylatis q.  s. 

Ft.  pil.  ent.  no.  L. 

M.  et  S.  Ten  (10)  at  night  as  directed. 


DYSENTERY— BACILLARY  AND  AMEBIC  385 

Give  10  pills  the  first,  second,  third,  fifth,  eighth,  twelfth,  etc.,  nights. 
If  nausea  or  diarrhea  occur  with  any  dose,  to  obviate  recurrence: 

9 

Sodii  Bromidi 5i  (4) 

Tr.  Opii  Deod 3i  (4) 

Aquae  Menth.  Pip.  q.  s giv        (120) 

M.  et  S.    One  (1)  tablespoonful  two  hours  before  taking  pills. 

Also,  for  nausea: 

Ice  bag  or  cold  water  to  abdomen. 

Seltzer,  ginger  ale  and  other  effervescing  drinks. 
Quinine. 

Colon  irrigations  of  quinine  hydrochloride  1-1000  to  1-500  about 

J^  gallon  an  hour  or  two  before  taking  the  ipecac  pills. 
Ulcers  and    mixed   infections   treated    as   in   Bacillary   Dysentery 

(Bethea). 

Hepatitis — Liver  abscess. 

For  prophylactic  treatment,  see  Stitt's  recommendations  above. 

Emetine. 

Dosage  and  administration  same  as  in  uncomplicated  dysentery. 

(See  above.) 
Abscess  aspirated  or  incised  and  drained. 

(For  technique  of  operation,  see  text.) 

Relapses. 

Treated  by  emetine  in  the  same  way  as  the  initial  attack. 
Ipecac  by  bowel. 

60  to  120  grains  (4-8  Gm.)  of  the  powdered  ipecac  in  24  ounces 
(720  c.c.)  of  water  kept  hot  (not  boiled)  for  an  hour  is  introduced 
into  the  bowel  and  retained  as  long  as  possible.    (Lawson.) 
Ipecac  by  mouth.    (See  Bethea's  method  above.) 
Quinine  in  high  enemata,  1-5000  up  to  1-1000  of  a  soluble  salt,  the 

dihydrochloride  and  urea  or  the  bisulphate  take  1  to  2  quarts 

(liters). 
Brook  claims  quinine  (as  above)  to  be  more  efficacious  than  emetine 

in  relapses. 

Other  drugs  than  emetine. 
Quinine  treatment  of  Brook. 

Dose,  gr.  xxii-xxx  (1.50-2  Gm.)  a  day  for  six  days. 

Stop  a  week,  then  repeat  the  series. 

Benzyl  benzoate. 

20  per  cent,  solution  in  alcohol.    Use  10-30  drops  three  times  a  day 
after  meals. 

Bitter  bush. 

(See  text.) 


386  TREATMENT  OF  ACUTE  INFECTIOUS  DISEASES 

Bismuth  subnitrate. 

3i  three  or  four  times  a  day. 

Protargol. 

1 :500  solution  used  by  the  bowel. 

Symptomatic  treatment. 
Pain  and  colic.  1 

Tenesmus.          >  (See  Bacillary  Dysentery  above.) 
Diarrhea. 

Sub-acute  and  chronic  stages  with  ulceration. 

Silver  nitrate.    (See  Bacillary  Dysentery  above.) 
Solutions  of  quinine  by  the  bowel,  1-2000  up  to  1-1000. 

Diet  in  chronic  cases. 

(See  Bacillary  Dysentery  above  and  Typhoid  Fever,  Chap.  XIV.) 

Carriers. 

Colon  irrigations  of  silver  nitrate,   1-2000  up  to  1-300,  increasing 

rapidly  if  the  bowel  shows  toleration. 
Irrigations  with  quinine  solution,  1-1000  up  to  1-500. 
Oil  of  Chenopodium. 
Dose — m.  xvi   (1  c.c.)  every  three  hours.    Precede  by  magnesium 

sulphate  and  follow  by  castor  oil. 
Surgery. 

In  most  intractible  cases  appendicostomy  followed  by  irrigations 
of  normal  saline  solution  or  1  per  cent,  bicarbonate  of  soda  or 
boracic  acid  solutions  to  cleanse  bowel  and  then  followed  by  1- 
10000  permanganate  of  potash  solution,  or  protargol,  1-500  or 
silver  nitrate  1-5000  to  1-2000,  quinine  solutions  aos  above. 

Prophylaxis. 

Boiling  of  drinking  water. 

Cooking  of  all  foods. 

Disinfection  of  excreta. 

Cleanliness  of  hands. 

Keeping  flies  from  stools  by  screening. 

War  of  extermination  on  the  fly. 

Detection  and  treatment  of  the  carriers.    (See  text.) 


CHAPTER  XVII 

SCARLET  FEVER 

THE  causative  agent  in  scarlet  fever  remains  unknown  up  to  the 
present  time,  but  the  close  association  of  the  streptococcus  pyogenes 
with  this  disease  and  its  certain  etiological  relationship  to  many  of  the 
most  serious  manifestations,  concomitant  or  sequential,  of  the  disease, 
makes  it  of  great  importance  from  the  standpoint  of  therapy. 

The  infection  probably  enters  the  body  through  the  nose  and  mouth 
and  is  conveyed  by  the  secretions  from  these  organs  in  the  act  of  cough- 
ing, sneezing,  talking,  spitting  or  by  objects  contaminated  with  these 
secretions,  such  as  eating  utensils,  handkerchiefs  and  towels.  The  period 
of  greatest  infection  is  probably  at  the  tune  of  the  early  rash.  There 
are  in  all  probability  chronic  carriers  and  especially  convalescents 
with  chronic  ear  discharge,  discharging  gland  or  persistent  catarrhal 
symptoms  of  nose,  throat  and  bronchi. 

The  period  of  incubation  is  an  important  one,  because  it  meas- 
ures the  time  during  which  a  child  exposed  to  scarlet  fever  may  become 
a  source  of  infection  to  other  children  and  the  time  during  which  contact 
with  other  children  should  be  avoided. 

Unfortunately,  there  is  no  precise  agreement  as  to  this  period  or, 
perhaps,  the  period  itself  varies  considerably,  resulting  in  statements  by 
various  observers  that  range  from  one  day  to  three  weeks.  Excellent 
authority  may  be  quoted  for  two  to  four  days  and  ten  to  fourteen  days. 
My  inclination  is  to  anticipate  the  shorter  period;  but,  considering  it 
from  the  standpoint  of  possible  danger  to  others,  to  set  the  limit  of  isola- 
tion of  the  exposed  at  three  weeks. 

This  may  be  an  excessive,  caution  as  some  of  our  best  State  Depart- 
ments of  Health  set  the  period  at  eight  days. 

The  onset  is  usually  abrupt,  beginning  with  vomiting  in  the 
vast  majority  of  the  cases,  a  sore  throat,  a  considerable  rise  of 
temperature,  and  in  twelve  to  twenty-four  hours  an  erythematous 
eruption. 

Unfortunately  for  the  clinician,  the  diagnosis  is  often  made  diffi- 
cult by  deviations  from  the  type.  The  eruption  may  be  delayed  for 
three,  four  or  five  days  or  be  atypical  or  evanescent.  The  sudden  onset 
with  vomiting,  sore  throat  and  a  rise  of  temperature,  should  always 
make  one  suspect  scarlet  fever.  The  bright  injection  of  the  throat, 


388  TREATMENT  OF  ACUTE  INFECTIOUS  DISEASES 

and  an  increasing  leucocytosis  and  polynucleosis  enhance  the  prob- 
ability. McCollom  lays  great  stress  on  the  hypertrophied  papillae 
at  the  tip  and  edge  of  the  tongue,  like  small  grains  of  cayenne  pep- 
per scattered  upon  it.  If  the  eruption  has  been  evanescent,  overlooked 
or  doubtful,  the  papillae  growing  daily  more  distinct,  the  increasing 
eosinophilia  as  the  temperature  disappears  and  the  leucocytosis  de- 
creases, the  evidences  of  desquamation  or  the  late  onset  of  nephritis 
finally  fixes  the  diagnosis  and  determines  certain  precautions  for  the 
patient  and  those  who  might  be  infected  by  him. 

Distribution  of  the  Family.  The  diagnosis  once  made  or  with 
good  reason  suspected,  immediate  measures  must  be  taken  to  protect 
other  members  of  the  family,  who  have  not  had  scarlet  fever. 

The  ages  of  the  individual  members  of  a  family  determine  differ- 
ent precautions. 

With  reference  to  the  adults,  two  facts  are  to  be  kept  in  mind; 
first,  that  recurrence  is  so  rare  that  those  who  have  had  it  have  little 
to  fear  for  themselves,  but  may  convey  the  disease  to  others;  hence, 
adult  members  of  the  family  should  come  in  contact  with  the  patient 
as  little  as  possible  and  those  who  may  come  in  contact  with  children 
outside  should  keep  remote  from  the  patient,  or,  if  the  contact  with 
other  children  is  intimate,  should  remove  from  the  house  during  the 
course  of  the  disease.  Teachers  should  remove  from  contact  with  the 
patient  and  notify  the  Public  Health  authorities.  They  should  not 
return  to  their  work  until  they  receive  the  consent  of  these  authorities. 
No  person,  who  has  come  into  contact  with  scarlet  fever,  should  handle 
food  supplies  for  eight  days. 

Second,  that  susceptibility  decreases  with  years;  McCollom's  figures 
show  that  of  5,000  cases  less  than  5  per  cent,  occurred  after  twenty-four. 
The  adult,  then,  who  has  not  had  the  disease,  runs  a  risk  which  should  be 
avoided  if  possible,  but  a  risk  that  is  so  slight  that  it  yields  to  pressing 
exigencies. 

The  other  children  in  the  family  should  be  removed  to  another 
house  and  there  kept  from  contact  with  other  children  until  the  longest 
period  of  incubation,  which  we  may  take  as  long  as  three  weeks,  has 
passed,  although  very  excellent  authority  is  content  with  eight  days. 
(Osborne,  Epidemiologist  of  Mass.  State  Board  of  Health.)  Their 
return  home  will  depend  on  the  patient's  length  of  illness  and  upon  the 
complications,  which,  themselves,  may  lengthen  the  period  of  infectivity, 
e.  g.,  discharging  ears. 

They  should  not  be  allowed  to  go  to  school  until  this  incubation  period 
has  passed  or,  if  there  is  communication  between  them  and  the  patient 
through  other  members  of  the  household,  they  should  not  return  to 


SCARLET  FEVER  339 

school  until  the  patient  is  recovered  and  the  danger  of  their  own  infec- 
tion is  passed. 

When  it  is  not  possible  to  remove  the  other  children,  every  contact 
with  the  patient,  direct  or  indirect,  must  be  avoided  to  the  best  of  the 
ability  of  those  concerned.  It  has  been  claimed  that  isolation  can  be 
effected  more  certainly  in  scarlet  fever  than  in  measles,  but  it  must  be 
remembered  that  the  susceptibility  to  the  former  infection  is  not  so  great 
as  is  the  case  in  the  latter;  hence,  dependence  on  such  isolation  cannot 
be  offered  as  a  reason  for  keeping  other  children  at  home,  if  it  be  possible 
to  remove  them. 

It  must  be  remembered,  too,  that  a  light  case  in  one  patient  in  no  way 
assures  that  the  infection  will  prove  light  in  the  others;  an  assumption 
to  which  parents  are  peculiarly  prone. 

All  contacts,  adults  and  children,  should  have  their  throats  and  skins 
inspected  and  temperatures  taken  two  or  three  times  a  day  at  least  dur- 
ing the  first  week,  to  determine  the  early  symptoms  of  the  disease.  If 
this  inspection  is  made  by  the  physician  in  attendance  on  the  case  it 
should  be  done  on  his  arrival  and  before  he  has  seen  the  patient  to  lessen 
the  possibility  of  becoming  himself  the  conveyor  of  the  infection. 

THERAPY 

Room.  To  begin  right  is  to  win  half  the  battle  and  an  unwill- 
ingness to  inconvenience  the  rest  of  the  family  must  not  stand  in  the 
way  of  the  patient's  needs.  That  room  in  the  house  which  will  meet 
the  demands  of  the  physician,  nurse  and  patient  best  must  be  given  up 
to  him.  The  demands  of  the  patient  are  space,  ventilation,  light, 
cleanliness;  those  of  the  nurse  are  economy  of  effort  in  managing 
the  room;  access  to  a  bath-room  devoted  to  the  patient;  nearness 
of  her  own  room;  those  of  the  physician,  ease  of  ingress  and  egress  with 
minimum  danger  to  the  family. 

This  ideal  can  be  attained  in  commodious  quarters,  but  only  ap- 
proximated elsewhere. 

The  room  must  be  large  enough  with  enough  windows  to  avoid  being 
stuffy  and  afford  good  ventilation,  without  exposure  to  draughts.  A  top 
floor  room  is  excellent  or  one  with  approach  to  a  balcony  or  one  at  the 
side  of  the  house  affording  a  special  entrance.  Moreover,  sunlight  as 
well  as  air  must  have  access  to  the  room.  Both  cleanliness  and 
economy  of  effort  are  afforded  by  stripping  the  room  of  furniture, 
carpet,  hangings,  pictures,  etc.  The  floor  may  be  bare  or  covered 
with  carpet  lining  and  over  this  unbleached  muslin.  An  open  fire-place 
has  its  advantages  for  the  sick  room. 


390  TREATMENT  OF  ACUTE  INFECTIOUS  DISEASES 

Isolation  is  made  more  complete  by  sealing  doors  leading  to 
other  rooms  or  hallways,  except  that  in  use.  This  sealing  may  be  done 
with  strips  of  paper  laid  along  the  cracks  and  reenforced  to  several 
thicknesses.  Gum  tragacanth  makes  an,,  excellent  paste,  is  easily  re- 
moved and  does  not  stain  or  injure  paint.  . 

The  admission  to  all  rooms  used  by  the  patient,  i.  e.,  the  sick 
room,  the  bath-room,  the  nurse's  room,  should  be  protected  by 
sheets.  If  the  first  entrance  is  to  the  bath-room  and  then  to  the 
sick  room,  both  entrances  may  well  be  protected.  An  arrangement 
that  has  advantages  is  two  sheets  to  the  door  entering  the  sick  room; 
one  on  the  inside  and  one  on  the  outside  of  the  entrance  or  portal.  The 
one  attached  to  the  top  and  right  side,  the  other  to  the  top  and  left 


The  floor  and  woodwork  should  be  rubbed  down  with  damp 
cloths  or  cloths  saturated  with  1  to  1,000  bichloride  of  mercury  from 
time  to  time  and  the  cloths  burned.  If  the  floor  is  covered,  then  the 
same  strength  bichloride  may  be  sprinkled  on  the  covering  from  time 
to  time.  It  is  customary  to  saturate  the  inner  sheet  with  1  to  20  carbolic 
or  with  bichloride  solution,  but  the  heavy  odor  of  the  carbolic  and  the 
amount  of  toxic  material  that  must  be  introduced  into  the  room  to  keep 
the  sheets  wet  through  all  the  weeks  of  illness  makes  it  objectionable. 

It  would  seem  better  to  replace  the  sheets  from  time  to  time,  destroy- 
ing the  old,  if  made  of  cheap  material  or  sterilizing  them  if  of  good 
material. 

The  Nurse.  In  a  disease  necessitating  so  close  confinement  and 
demanding  so  close  attention,  there  should  be  both  a  day  and  a 
night  nurse.  If  this  be  not  feasible,  a  member  of  the  family  should  lend 
assistance,  but  then  should  be  as  completely  isolated  from  the  rest  of 
the  family  as  the  nurse.  When  nursing  devolves  on  the  mother  or  other 
member  of  the  family  their  isolation  from  the  rest  of  the  family  is  a  duty 
that  must  be  emphasized  by  the  physician  and,  all  the  more,  because  it  is 
iso  difficult  to  make  the  necessity  understood  and  observed. 

In  the  presence  of  the  patient  the  nurse  should  wear  a  gown  and 
a  cap  that  covers  the  hair  completely  and  in  the  care  of  a  bad 
throat  and  in  the  handling  of  secretions,  rubber  gloves. 

An  occasional  antiseptic  spray  to  the  throat  is  a  wise  precaution. 
The  nurse  should  not  come  in  contact  with  other  members  of  the  family 
or  with  people  outside  the  sick  room  unless  the  occasion  be  imperative 
and  then  she  should  subject  herself  to  the  same  kind  of  disinfection  as  on 
leaving  the  case.  The  nurse  should  not  sleep  or  eat  in  the  sick  room,  but 
should  have  a  room  adjacent  to  the  sick  room  devoted  to  herself. 

Taking  air  or  exercise,  the  nurse  should  choose  that  time  of  day  and 


SCARLET  FEVER  391 

those  localities  that  minimize  the  possibility  of  contact  with  susceptible 
individuals.  Clothes  should  be  changed  and  hair  washed. 

The  Physician.  In  an  outer  room  the  physician  should  leave 
his  overcoat  or,  better  yet,  his  coat  and  vest,  and  entering  the  bath- 
room or  some  small  ante-room  where  his  accouterments  for  the  sick 
room  are  left,  don  a  gown  reaching  the  floor,  and  tight  at  wrists  and 
neck.  In  addition  he  should  have  a  cap  to  cover  the  hair,  and  a  pair 
of  rubber  gloves  if  he  is  to  examine  the  throat,  as  he  ought  to 
do.  Wearing  rubber  shoes  and  turning  up  the  trousers  are  precau- 
tions worth  observing.  All  instruments  used  in  routine  examination, 
including  the  stethoscope,  should  be  left  in  the  sick  room  or  bath-room 
and  disinfected  before  using  again. 

While  an  honest  and  conscientious  examination  of  the  patient  should 
be  made,  undue  loitering  and  prolonged  examinations  only  add  to  the 
peril  of  some  other  patient. 

On  leaving  the  patient,  the  physician  leaves  the  gown,  cap,  shoes  and 
gloves  in  the  bath-room  or  ante-room,  and  washes  his  face  and  hands 
thoroughly  with  soap  and  water.  This  is  more  important  than  the 
antiseptic  to  follow,  in  the  efficacy  of  which  the  physician's  faith  is 
often  of  too  childlike  simplicity. 

Following  the  soap  and  water,  alcohol,  preferably  50%,  furnishes  an 
excellent  antiseptic,  or  bichloride  in  the  strength  of  1  to  1000  or  carbolic 
or  lysol  in  the  strength  of  1  per  cent.;  but  to  both  the  carbolic  and  lysol 
the  objection  of  the  clinging  and  disagreeable  odor  attaches,  while  they 
are  less  efficacious  than  those  mentioned. 

When  a  gown  may  not  be  obtained,  a  sheet  may  be  arranged  about 
the  person  in  such  a  way  as  to  effect  the  same  purpose  as  a  gown.  In  the 
absence  of  any  such  protection  or  in  a  visit  to  a  suspected  case,  the 
overcoat  and  street  gloves  may  be  worn. 

Full  duty  to  the  public  who  trust  the  physician  is  done  only  when 
he  changes  his  clothes  and  better  yet  takes  a  full  bath  before  seeing 
other  children.  Unfortunately,  this  is  a  rule  rarely  followed;  hence,  only 
the  most  rigid  precautions  on  occasions  of  visits  to  the  scarlet-fever 
patient  can  minimize  the  danger  entailed  by  such  a  failure  of  proper  ob- 
servances. He  should  plan  to  see  the  case  only  early  or  late  or  allow 
•some  interval  between  this  visit  and  the  next  on  a  child,  spent  in  the 
open  air.  He  should  not  take  obstetrical  cases  or  do  surgery. 

Precautions  in  the  Sick  Room.  Articles  in  common  use  about 
the  patient,  when  of  such  a  nature  as  to  permit  it,  should  be  kept  in  an 
antiseptic  solution.  The  thermometer  must  be  left  with  the  patient. 
No  effort  at  disinfection  will  justify  its  use  among  other  patients.  It 
may  be  kept  in  carbolic,  2  per  cent,  or  stronger  up  to  saturation,  1  in 


392  TREATMENT  OF  ACUTE  INFECTIOUS  DISEASES 

20.  The  tongue  depressor  should  be  of  wood  or  glass.  If  of  wood, 
to  be  destroyed  by  burning  after  each  usage;  if  of  glass,  kept 
in  carbolic  like  the  thermometer.  Syringe  nozzles  whether  of  hard 
rubber  or  glass  (and  they  should  not  be  of  glass  when  used  to  irrigate 
the  throats  of  young  children,  lest  they  be  bitten  and  broken),  are  to 
be  treated  in  the  same  manner. 

Dishes,  knives,  fork,  spoons  used  by  the  patient  or  nurse 
should  be  boiled  for  at  least  a  half  hour.  A  small  gas  stove  in  the  bath- 
room or  adjoining  room  facilitates  the  procedure.  If  the  utensils  are 
removed  from  the  sick  room  to  be  boiled,  they  should  first  be  soaked 
in  1-20  phenol  (carbolic)  for  20  minutes  to  1/2  hour. 

Urinals,  bed-pans  and  sputum  cups  should  be  disinfected  with 
phenol  (carbolic)  one  in  twenty  and  the  same  strength  carbolic  should 
stand  in  them  when  not  in  use. 

Bed-linen  should  be  soaked  overnight  in  phenol  (carbolic),  1-50 
to  1-20,  and  then  boiled  for  a  half  hour  before  being  sent  to  the  wash. 

Discharges  from  the  mouth,  nose  and  ears  are  better  caught 
on  pieces  of  gauze  or  cloth  that  can  be  burned  at  once. 

Cats,  dogs  and  birds  should  be  excluded.  Only  a  few  books  or  toys 
and  such  only  as  may  be  destroyed  later  are  permissible. 

Temperature  of  the  Room.  Thorough  ventilation  with  avoid- 
ance of  draughts  upon  the  patient  is  the  desideratum;  65°  F.  to  70°  F. 
are  the  figures  usually  given  and  are  useful  to  prevent  overheating  in 
the  colder  months,  but  in  the  winter,  cold  itself  is  not  dangerous  but 
helpful,  providing  the  patient's  body  is  properly  protected  and  the 
temperature  brought  up  to  70°  F.  before  the  body  is  exposed  for  any 
purpose. 

Bed.  See  Pneumonia,  Chap.  IX.  The  weight  of  clothing  is 
determined  by  the  comfort  of  the  patient  and  the  temperature  of  the 
room. 

Patient.  The  patient  must  be  put  to  bed;  an  injunction,  which 
while  unnecessary  in.  severe  cases,  meets  with  opposition  in  the  mild 
ones.  An  explanation  of  the  consequences,  in  terms  of  kidney  compli- 
cations, especially,  will  persuade  the  parents. 

A  tepid  sponge  bath  is  given  each  day,  which,  given  on  a  blanket, 
exposing  one  part  after  another,  in  a  warm  room,  entails  no  danger. 

Nightgown.  This  should  be  of  flannel  and  if  this  is  too  irritating 
to  the  skin,  a  thin  cotton  or  silk  undervest  may  be  worn  under  it. 

Diet.  No  person  in  contact  with  the  patient  should  prepare 
the  food  for  the  family  nor  should  the  nurse  come  into  contact  with 
the  general  food  supply  of  the  family. 

The  diet  in  scarlet  fever  is  determined  by  the  same  fundamental  princi- 


SCARLET  FEVER  393 

pies  as  obtains  in  the  arrangement  of  a  dietary  in  other  acute  infections, 
except  so  far  as  the  frequency  of  nephritis  may  modify  it:  (See  Diet 
in  Acute  Infectious  Disease,  Chap.  II)  i.  e.,  in  the  first  few  days  of  the 
infection,  when  anorexia  is  marked  or  the  angina  entails  much  suffering 
from  the  act  of  deglutition,  the  feeding  should  not  be  pushed  beyond 
the  patient's  inclination;  but  after  that  period  has  passed,  the  theoretical 
needs  of  the  body  must  be  taken  into  consideration. 

The  frequency  and  severity  of  the  nephritis  which  comes  late  in  the 
course  of  scarlet  fever  determines  greater  precautions  in  scarlet  fever 
than  in  any  other  of  the  acute  infections. 

Many  authors  write  as  if  any  article  of  food  other  than  milk  might 
precipitate  an  attack  of  nephritis.  I  think  we  are  convinced  to-day 
that  the  nephritis  is  due  to  the  toxins  of  the  disease  or  to  other  infectious 
organisms  or  their  toxins  accompanying  the  disease,  such  as  the  strep- 
tococcus, whose  action  would  not  be  modified  favorably  by  an  insuffi- 
ciency in  quantity  or  quality  of  food.  That  a  constant  examination  of 
the  urine  for  the  first,  least  evidence  of  nephritis  should  be  made,  ought 
to  be  emphasized  and  when  such  evidence  appears,  then  the  kidney 
should  be  given  the  greatest  degree  of  rest  compatible  with  the  imper- 
ative needs  of  the  rest  of  the  organism,  like  any  other  damaged  organ. 

The  consensus  of  opinion  is  that  milk  has  proved  itself,  empirically, 
to  be  the  best  single  article  of  food  in  scarlet  fever;  but  that  it  should 
be  the  only  article  of  food  in  scarlet  fever  or  that  it  has  proven  to  be 
specific  as  a  preventative  of  nephritis  is  doubtful. 

The  three  great  functions  of  the  kidney  are  the  elimination  of  water, 
of  salts  and  of  nitrogen.  It  is  desirable  to  heap  no  excess  of  the  one 
or  the  other  upon  the  kidney.  They  are  nicely  proportioned  in  milk; 
for  example,  2  quarts  of  milk  furnishes  about  the  average  water  intake 
for  twenty-four  hours.  In  these  2  quarts  of  milk  are  about  70  grams  of 
proteid,  or  11  grams  of  nitrogen.  While  this  amount  of  proteid  is  below 
the  average  proteid  intake  of  a  man  in  health,  it  is  enough  to  maintain 
him  in  health,  as  Chittenden's  experiments  showed  and  in  disease  a 
"luxus  consumption "  should  be  avoided  as  putting  a  burden  on  the 
kidney.  In  these  2  quarts  of  milk  are  about  3  grams  of  salt. 

This  amount  is  way  below  the  average  salt  intake,  but  in  health  we 
use  salt  largely  as  a  condiment  and  so  small  amounts  as  here  given  more 
than  meet  the  actual  physiological  needs.  Moreover,  sodium  chloride 
is  illy  excreted  when  the  tubules  of  the  kidney  become  impaired. 

Two  quarts  of  milk,  however,  furnish  but  1,280  calories  of  food; 
less  than  50  per  cent,  of  the  demands  of  a  man  of  average  weight  in 
fever.  If  sufficient  milk  were  given  to  meet  the  caloric  needs  of  3,000 
calories,  twice  as  much  proteid  and  twice  as  much  water  as  is  required 


394  TREATMENT  OF  ACUTE  INFECTIOUS  DISEASES 

would  be  administered.  To  meet  the  caloric  needs,  either  the  milk 
must  be  fortified  or  other  articles  added.  The  milk  may  be  fortified 
by  adding  to  each  glass  milk-sugar  or  cream  or  both.  One  ounce  of 
cream,  16  per  cent.,  50  calories,  7  ounces  -of  milk,  140  calories  and  1/2 
ounce  of  milk-sugar,  60  calories,  makes  250  calories  to  each  glass  of  8 
ounces  or  2,000  calories  to  the  2  quarts. 

Additional  sugar  may  be  introduced  in  such  drinks  as  lemonade  or 
orangeade. 

Other  milk  preparations,  cereal  gruels,  well-cooked  cereals  (oatmeal 
has  been  objected  to  an  account  of  a  high  purin  content),  bread  and 
butter,  milk  toast  are  suitable  for  the  dietary.  Among  the  cereals  and 
flours  are  to  be  mentioned  arrowroot,  rice,  barley,  cornstarch,  flour, 
farina,  imperial  granum;  all  of  which  can  be  made  into  gruels;  or  they 
may  be  used  without  the  milk  in  the  shape  of  jellies  of  barley  flour, 
tapioca,  sago  or  thoroughly  cooked  farina,  rice,  cornmeal. 

Vanilla  ice-cream  or  lemon  ice  may  be  allowed  from  time  to  time. 

The  basis  of  the  dietary,  then,  is  milk;  modifications  of  milk,  such 
as  koumys,  buttermilk,  matzoon,  zoolak,  cereal  gruels,  cereals,  bread 
and  butter  and  milk  toast  being  added  when  the  milk  disagrees  or 
when  the  appetite  lags  from  the  monotony  of  the  diet. 

After  the  period  when  a  nephritis  is  likely  to  ensue,  more  articles 
may  be  added  to  the  diet;  eggs,  custard,  potatoes*,  other  vegetables, 
oysters,  fish  and  finally  meat. 

Meat  soups  should  be  avoided  at  all  stages,  because  they  contain 
largely,  almost  exclusively,  nitrogenous  extractives  which  have  little 
or  no  nutritional  value,  but  must  be  excreted  by  the  kidneys. 

CALORIC  VALUES 

Milk 20  Calories  per  ounce 

Cream,  gravity .' , 50  Calories  per  ounce 

Koumys 14  Calories  per  ounce 

Buttermilk 10  Calories  per  ounce 

Whey 7.5  Calories  per  ounce 

Sugar 120  Calories  per  ounce 

Bread 100  Calories  per  slice   (about  12 

slices  to  a  1-pound  loaf) 

Barley  (meal  or  flour) 1640  Calories  to  the  pound 

Wheat  flour 1625  Calories  to  the  pound 

Farina 1685  Calories  to  the  pound 

Baked  custard . 183  Calories  to  2  heaping  table- 
spoonfuls 

Tapioca 1650  Calories  per  pound 

Rice 1630  Calories  to  the  pound 

Cornmeal 1655  Calories  to  the  pound 

Butter 119  Calories  per  ball  (%  ounce) 


SCARLET  FEVER  395 

Oysters 88  Calories  per  dozen 

Fish 100-150  Calories  per  %  pound 

Eggs 70-80  Calories  per  egg 

Potatoes  (white) About  100  Calories  for  medium  size 

(4  to  5  ounces) 

The  caloric  requirements  in  short  acute  infections  may  be  disregarded. 

The  caloric  requirements  in  prolonged  infections  are  some  25  per 
cent,  more  than  in  health  and  often  much  more  is  taken  with  benefit. 

We  try  to  meet  the  theoretical  requirements,  while  not  disregarding 
the  patient's  appetite  and  wishes  too  violently,  but  if  the  patient  will 
take  more  than  these  requirements  willingly  and  handles  it  well  we 
should  give  it  to  him. 

Water.  Water  or  lemonade  or  orangeade  or  the  juice  of  grape 
fruit  or  grapes  may  be  given  freely.  Imperial  drink,  a  tablespoonful 
of  cream  of  tartar  (acid  potassium  tartrate)  to  3  pints  of  boiling  water 
(to  get  it  in  solution)  to  which  sugar  and  lemon  peel  is  added  to  suit 
the  flavor,  is  a  grateful  drink  and  a  good  diuretic. 

The  amount  of  fluid  to  be  taken  should  be  well  above  the  2  quarts 
taken  in  health.  Drink  should  be  offered  every  hour  and  the  patient 
allowed  to  take  such  quantities  as  he  will.  It  must  not  be  left  to  the 
patient  to  ask,  as  he  is  often  too  sick  to  do  so. 

Skin.  The  patient  should  have  a  sponge  bath  once  or  twice 
a  day  both  for  comfort  and  cleanliness.  It  should  be  done  in  a  warm 
room,  between  blankets  and  as  a  precaution  against  chilling,  which 
in  a  fever  seems  to  me  over- exaggerated,  one  part  of  the  body  at  a  time 
is  exposed  for  the  bath. 

Itching  and  burning  of  the  skin  is  often  an  annoying  feature 
of  the  exanthem.  This  may  be  allayed  by  sponging  with  a  solution 
of  soda  bicarbonate,  a  teaspoonful  in  3  pints  of  water,  or  a  bran 
bath,  a  handful  of  bran  in  a  muslin  or  cheesecloth  bag  immersed 
in  a  gallon  of  water  until  it  becomes  slightly  milky  in  appearance,  or 
the  skin  can  be  kept  well  dusted  with  a  rice  or  talcum  powder. 

Calamine  lotion,  5i  (4  Gm.)  calamine  to  1  pint  (500  c.c.)  of 
lime  water.  For  extreme  itching  1  per  cent,  to  2  per  cent,  phenol 
in  olive  oil. 

When  exfoliation  begins  cocoa-butter,  or  vaseline  may  be  ap- 
plied; if  1  per  cent,  to  2  per  cent,  phenol  be  added  to  the  latter  it 
allays  the  itching  and  burning.  Cold  cream  (ointment  of  rose  water) 
affords  an  excellent  application. 

Soaking  in  warm  water  helps  to  get  off  the  peeling  skin;  picking, 
rubbing  and  scraping  the  skin  to  expedite  the  desquamation  is  not 
justifiable,  for  it  wounds  the  skin  and  opens  antra  of  infection. 


396  TREATMENT  OF  ACUTE  INFECTIOUS  DISEASES 

The  care  of  the  mouth,  throat  and  nose  is  of  supreme  impor- 
tance, because  the  throat  is  often  the  seat  of  streptococcus  or  other 
pyogenic  invasion,  which,  neglected,  may  permit  of  the  spread  of  the 
infection  by  direct  extension,  into  the  ears-;  air  passages,  nose  and  acces- 
sory sinuses,  while  by  way  of  the  blood  stream  and  lymphatics,  the 
glands,  joints,  kidneys  and  heart  may  be  attacked. 

All  procedures  must  be  thoroughly  and  conscientiously  carried  out, 
but  with  extreme  gentleness,  because  of  the  pain  produced  by  careless- 
ness, but  much  more  because  the  wounded  surface  invites  the  entrance 
of  infection.  For  the  same  reason,  mild  applications  are  indicated. 

Physiological  salt  solution  Si  to  Oi  (4  Gm.  to  500  c.c.),  boric  acid 
solution,  2  per  cent,  to  4  per  cent.,  or  half  strength  Dobell's  Solution 
(a  weak  solution  of  bicarbonate  of  soda  and  borax,  aa  5ii  to  Oi  (8  Gm.- 
500  c.c.)  with  about  1/3  of  1  per  cent,  phenol  (carbolic  acid)  seem  to  me 
to  be  the  safest  substances  to  use  whether  in  the  shape  of  simple  mouth 
wash,  spray  or  irrigation.  Any  of  the  mild  alkaline  solutions,  so-called 
antiseptic  solutions,  marketed  under  various  names  offer  an  agreeable 
substitute. 

After  taking  food  the  mouth  should  be  rinsed  with  one  of  these  solu- 
tions, the  teeth  cleansed  with  a  cotton  swab  on  a  wooden  tooth 
pick  wet  in  the  solution  and  the  dead  spaces  between  lips  and  teeth 
and  teeth  and  cheeks  searched  for  particles  of  food  or  collections  of 
secretions  by  the  same  means. 

The  sicker  the  patient  the  more  painstaking  should  be  this  search. 

For  sordes  on  lips  or  teeth  and  for  the  thick  coat  upon  the 
tongue,  half  strength  solution  of  hydrogen  dioxide  (official)  should  be  ap- 
plied before  the  milder  solutions.  Much  of  the  coat  may  be  removed 
from  the  tongue  by  gently  scraping  the  tongue  after  this  treatment 
with  the  edge  of  a  whalebone,  but  there  must  be  no  violence. 

When  the  mouth  is  very  dry  equal  parts  of  2  per  cent,  boric 
acid  solution  and  albolene  (liquid  petrolatum)  with  a  little  lemon  juice 
added  is  efficacious  and  pleasing.  If  the  breath  is  fetid,  the  mouth  foul 
and  stomatitis  in  evidence  one  may  make  an  application  of  the  following 
solution: 

3 

Phenol  (watery  solution  1  in  20) 

Glycerin aa  3i  (4  c.c.) 

Boric  Acid  (saturated  watery  sol.) gviii        (240  c.c.) 

M. 

This  is  followed  by  the  milder  solution. 

The  same  solutions  may  be  used  for  the  nose;  dried  secretions  being 
previously  moistened  and  softened  by  application  of  sweet  oil  or  vaseline. 


SCARLET  FEVER  397 

Application  should  be  made  with  cotton  on  a  tooth  pick  and  very  gently. 
Sprays  may  also  be  used. 

Irrigations  are  to  be  avoided  unless  special  indications  arise,  as  the 
solution  may  make  its  way  with  infectious  material  into  the  Eustachian 
tube  and  set  up  middle  ear  disease. 

For  the  throat  gargles  are  of  little  use.  The  spray  is  much  better 
and  irrigations  of  hot  saline  solution  3i  to  Oi  (4  Gm. — 500  c.c.)  are  safer 
here  and  very  grateful.  The  milder  solutions  are  to  be  used  unless  the 
angina  is  severe. 

The  genitals  should  be  carefully  inspected  and  kept  clean  by  the 
use  of  the  same  solutions. 

Bowels.  When  first  seen  a  free  catharsis  should  be  induced, 
one  or  two  watery  stools.  One  may  begin  with  calomel  in  gr.  1/4  (0.015 
Gm.)  doses  every  1/4  hour  for  four  or  five  doses  and  follow  with  salts. 

Calomel  is  easily  taken  and  well  borne  by  children  in  these  doses 
and  if  there  is  nausea  the  calomel  acts  as  an  antiemetic.  In  the  child 
this  dose  may  be  followed  by  milk  of  magnesia  gss.  (15  c.c.)  or  liq. 
magnesii  citratis  5vi  to  viii  (180  c.c.-240  c.c.)  or  Rochelle  salt  5ii  (8 
Gm.).  In  the  adult  the  doses  of  salt  are  doubled  or  Epsom  salt  or 
Glauber's  salt  may  be  given  in  doses  of  5ss.  (15  Gm.). 

If  nausea  continues,  cracked  ice,  or  bicarbonate  of  soda  in  doses  of 
gr.  x-xv  (0.60-1  Gm.),  may  be  used,  or  small  doses  of  bismuth  gr.  xv 
(1  Gm.)  or  of  cerium  oxalate  gr.  v  (0.30  Gm.)  are  of  value.  An  excellent 
prescription  calls  for  a  combination, 

3 

Bismuth  Subnitratis gr.  xv        (1.00  Gm.) 

Sodii  Bicarbonatis gr.  x          (0.60  Gm.) 

Cerii  Oxalatis gr.  v         (0.30  Gm.) 

M. 

This  may  be  given  stirred  in  a  little  water  and  repeated  at  two-hour 
intervals  if  needed. 

The  bowels  should  be  kept  open  by  the  use  of  enemata  every  other 
day  or  by  mild  cathartics,  such  as  liq.  magnesii  citratis,  Hunyadi  water 
or  cascara. 

TREATMENT  OF  SYMPTOMS 

Fever.  It  is  well  to  bear  in  mind  that  the  symptoms  of  dis- 
ease are  often  of  conservative  significance,  of  purposeful  intent,  subserv- 
ing some  definite  function  in  combating  the  agents  of  disease  or  the 
results  of  their  invasion,  and  that  interference  is  indicated  only  when 
this  purpose  has  failed  and  when  pyrexia,  too,  is  adding  a  burden,  not 
to  be  endured. 


398  TREATMENT  OF  ACUTE  INFECTIOUS  DISEASES 

Fever,  so  far  as  we  can  read  its  signs,  points  rather  to  the  establish- 
ment of  a  condition  in  an  acute  infection  which  enhances  the  efforts  and 
efficacy  of  the  various  modes  of  reaction  against  the  causative  agent  and 
its  products.  If  we  accept  this  view  there  Is  no  reason  to  attack  temper- 
ature under  all  circumstances  and,  as  often,  with  measures  themselves 
harmful.  But  we  have  to  learn  that  this  useful  temperature  may,  under 
conditions,  become  in  itself  a  danger.  These  conditions  are  excessive 
temperature  or  long  sustained  temperature  and  that  the  term,  hyper- 
pyrexia  is  a  relative  one;  for  a  febrile  reaction  of  105°  F.  would  scarcely 
be  considered  as  hyperpyrexia  if  of  short  duration;  it  becomes  a  decided 
hyperpyrexia  if  sustained  for  days.  Another  fact  to  be  borne  in  mind  is 
that  the  fever  is  loaded  with  the  onus  of  the  toxic  effects  of  the  materies 
morbi  upon  the  nervous  system  and  upon  the  cardio-vascular  and  respira- 
tory apparatus.  The  measures  that  empiricism  has  directed  against 
fever  are  successful  because  they  combat  the  effects  of  toxemia  upon 
the  organs  mentioned. 

A  moderate  degree  of  fever,  then,  104°  F.  or  below  is  to  be  let  alone, 
unless  accompanied  by  other  evidences  of  toxemia,  but.  when  above  this 
and  sustained,  efforts  are  to  be  made  to  reduce  it.  (For  niore- detailed 
discussion  of  fever  see  Chap.  I.) 

The  one  measure  that  outranks  any  other  as  an  antipyretic  both 
in  its  efficacy  and  safety  is  the  application  of  cold  through  water  as 
the  conveying  agent. 

For  infants  sponging  is  best;  for  children  the  pack  and  sponging;  for 
early  and  middle  adult  life  the  pack  or  bath. 

Neither  the  eruption  nor  the  fear  of  kidney  complications  should 
contraindicate  the  measure. 

We  are  discussing  here  hyperpyrexia  as  such  and  the  object  of  any 
procedure  is  extraction  of  heat.  It  is  well  with  children  to  begin  with 
water  relatively  warm,  95°  F.  to  90°  F.  and  increase  the  degree  of  cold, 
to  80°  F.,  75°  F.  and  70°  F.  or  colder,  the  degree  of  cold  and  the  length  of 
the  bath  depending  on  the  result  in  terms  of  reduced  temperature  and 
the  reaction  of  the  patient. 

The  patient  is  to  be  carefully  watched.  When  the  temperature  falls 
to  102°  F.  or  thereabouts,  the  bath  should  be  interrupted. 

If  the  patient  becomes  thoroughly  chilled  or  shows  any  evidences  of 
collapse,  the  procedure  should  stop,  the  patient  be  wrapped  in  a  dry 
blanket,  heat  placed  at  the  extremities  and  hot  drinks  given. 

When  high  temperature  is  accompanied  by  collapse  and  clammy 
extremities,  heat  should  be  applied  to  the  extremities  and  cold  in  the 
shape  of  compresses  or  sponges  to  the  trunk. 

Angina.    Strictly   speaking   angina    is   a   complication    of    scarlet 


SCARLET  FEVER  399 

fever,  but  a  complication  so  frequent  that  it  may  well  be  considered  as 
characteristic. 

We  are  considering  here  not  the  erythematous  angina,  which  has 
just  been  touched  upon  in  considering  the  care  of  the  mouth,  but  the 
membranous  or  gangrenous  angina.  A  membranous  angina  may  occur 
in  every  degree  of  severity,  from  a  small  patch  here  and  there  to  a  spread- 
ing membrane,  covering  tonsils,  palate,  pharyngeal  wall  and  invading 
the  nose  and  Eustachian  tubes.  The  gangrenous  type  may  be  secondary 
to  the  membranous  or  occur  as  primarily  such. 

The  invasion  of  the  nose  and  the  sinuses,  the  middle  ear,  the  ac- 
companying adenitis,  the  possible  pneumonia,  the  ensuing  nephritis, 
the  severity  of  the  toxemia  and  the  fact  that  not  only  the  streptococcus 
but  the  Klebs-Loffler  bacillus  may  be  concerned  in  the  formation  of 
the  membrane  make  the  condition  not  infrequently  a  most  serious 
menace  to  life,  demanding  the  most  conscientious  and  scrupulous  con- 
sideration. 

In  the  first  place  let  it  be  emphasized  that  the  presence  of  membrane 
should  mean  diphtheria  until  excluded  and  while  in  the  majority  of 
cases  the  diphtheria  bacillus  is  not  present  the  percentage  in  which  it 
is,  especially  in  hospital  practice  which  represents  patients  drawn  from 
the  poorer  and  congested  districts,  is  alarmingly  large. 

One  should  never  trust  to  clinical  descriptions  for  differentiation, 
but  take  a  culture  in  each  instance.  If  such  facilities  are  not  at  hand, 
the  patient  should  be  given  the  benefit  of  the  doubt  and  a  sufficient 
dose  of  antitoxin,  10,000  units.  If  the  case  is  a  very  severe  one  and  un- 
checked by  cultural  data,  the  antitoxin  should  be  used  as  in  a  case  of 
diphtheria. 

When  the  culture  is  taken,  wait  upon  the  report  and,  if  positive, 
treat  as  a  diphtheria.  If  there  is  any  laryngeal  involvement,  it  is  almost 
sure  to  be  diphtheritic  and  the  antitoxin  should  be  used  at  once,  not 
awaiting  the  return  on  the  culture.  Give  10,000  units  and  repeat  in 
eight  hours  if  no  improvement  or  in  four  or  six  if  getting  worse. 

Whether  the  membrane  is  due  to  streptococcus  alone  or  to  both  it 
and  the  diphtheria  bacillus,  the  procedure  is  the  same,  in  other  respects 
than  in  the  administration  of  the  serum. 

Two  facts  are  to  be  kept  in  mind.  1.  That  cleanliness  of  the  parts 
is  the  desideratum  and  that  the  mildest  solutions  and  the  mildest 
manipulations  must  be  used.  2.  That  the  local  condition  can  be  ag- 
gravated and  its  spread  and  invasion  of  other  structures  be  facilitated 
by  injury  to  the  parts,  either  through  the  irritating  or  corrosive  effects 
of  the  applications  or  the  mechanical  injury  done  in  the  application; 
and  that  it  is  extremely  doubtful  if  any  of  the  so-called  antiseptics 


400  TREATMENT  OF  ACUTE  INFECTIOUS  DISEASES 

have  any  effect  to  kill  appreciable  amounts  of  the  infecting  organ* 
isms. 

The  modes  of  application  are  irrigations,  gargles,  sprays,  inhalation 
of  vapor  and  topical  application  with  a  swab. 

The  most  reliable  of  all  these  modes  of  application  is  the  irriga- 
tion and  the  most  useful  substance  hot  physiological  salt  solution, 
one  teaspoonful  of  common  salt,  sodium  chloride,  to  the  pint  of  water. 

The  patient's  head  is  supported  by  pillow  or  rest  unless  too  sick, 
then  the  head  may  be  turned  to  one  side,  a  towel  tied  about  the  neck, 
a  pus-basin  or  other  receptacle  held  beneath  the  chin  and  the  stream 
of  saline  directed  from  a  fountain  syringe  or  irrigator  held  a  few  inches 
above  the  head,  but  not  high  enough  to  exert  force,  through  a  hard 
rubber  nozzle,  or  through  a  rubber  tube,  such  as  a  catheter,  against  the 
affected  parts,  the  tongue  being  gently  depressed  with  a  wooden  or 
glass  tongue  depressor.  If  very  young  children  are  so  treated,  the  nozzle 
may  be  placed  between  the  molar  teeth  and  the  stream  directed  to  the 
tonsils  and  pharynx.  The  excess  runs  out  into  the  basin. 

The  amount  used  should  be  1  pint  to  2  quarts,  according  to  the 
demands  and  the  effects  on  the  patient.  The  temperature  should  be 
as  hot  as  can  be  comfortably  borne.  One  must  determine  this  empiri- 
cally, beginning  with  a  temperature  of  110°  F.  to  115°  F.  in  the  adult 
and  100°  F.  in  the  young  child. 

The  frequency  every  two  to  three  hours  in  the  day  and  every  four 
hours  at  night. 

Not  only  does  this  clear  the  throat  of  secretions  and  wash  away  loose 
membrane,  but  it  relieves  the  pain  in  no  small  measure  and  induces  a 
moderate  degree  of  hyperaemia,  which  may  itself  be  a  factor  in  resolu- 
tion. 

Half  saturated  boric  acid  solution,  2  per  cent.,  or  Dobell's  solution 
diluted  from  two  to  four  tunes  may  be  used  as  the  irrigating  fluid. 

If  there  is  much  tenacious  mucus  in  the  throat,  an  abundant  spray 
or  preliminary  irrigation  with  a  solution  of  sodium  bicarbonate  gr.  xx 
(1.30  Gm.)  to  the  ounce  or  one  containing 

Sodii  Bicarbonatis 

Sodii  Biboratis aa  gr.  xxx        2  Gm. 

Aquae  dest.  q.  s.  ad 5  iv         120  c.c. 

M. 

(L.    Browne  in  Coakley  on  Diseases  of  the  Nose  and  Throat.) 

may  be  used  to  rid  the  throat  of  this  material  before  the  saline  irrigation 
is  given. 

If  there  is  a  considerable  deposit  of  membrane  or  in  any  case,  appli- 
cations, preferably  by  spray  or  very  gently  with  the  swab,  of  full  strength 


SCARLET  FEVER  401 

of  peroxide  of  hydrogen  may  be  used.  It  may  be  better  borne  in  full 
strength  on  the  swab  than  in  the  spray  and  the  latter  diluted  one  to 
two  or  three  times. 

In  a  bad  throat,  then,  one  may  get  rid  of  the  tenacious  mucus  by 
the  alkaline  spray,  then  touch  the  exudate  with  the  peroxide  of  hydrogen 
and  finally  use  the  hot  saline  irrigation.  If  the  process  is  fatiguing,  or 
causes  discomfort,  it  must  be  simplified  as  much  as  is  consistent  with 
results. 

Sprays  of  saline,  boric  acid  solution  or  Dobell's  as  above  may  be  given 
between  the  irrigations  as  often  as  they  prove  grateful  to  the  patient. 

Inhalations  of  hot  vapors  are  sometimes  appreciated  by  the 
patient.  It  may  be  merely  steam  or  steam  medicated  with  compound 
tincture  of  benzoin,  3i  to  the  pint  of  hot  water  or  oil  of  eucalpytus. 

These  may  be  used  in  a  croup  kettle  or  one  of  the  simple  devices  on 
the  market  or  a  common  kettle  with  a  cone  at  the  nozzle  to  direct  the 
steam  or  a  pitcher  of  hot  water  with  a  cone  over  it. 

Gargles  are  in  no  sense  a  substitute  for  irrigation  or  spray,  first, 
because  they  do  not  reach  the  affected  part  thoroughly  and,  second, 
because  the  act  of  gargling  is  in  itself  often  very  painful.  If  the  patient, 
however,  finds  relief  by  such  a  measure  there  is  no  contraindication. 
One  uses  the  same  substances  as  in  the  spray  or  irrigation. 

Cracked  ice,  held  in  the  mouth  and  sucked,  often  gives  great  com- 
fort. 

Cold  applied  to  the  neck  in  the  shape  or  compresses  or  coils  or  ice- 
bags  may  afford  great  relief.  They  must  be  properly  applied  and  not 
allowed  to  annoy. 

If  heat  is  the  more  grateful,  it  may  be  applied  in  the  shape  of  hot 
cloths. 

In  gangrenous  cases  one  may  use  an  irrigation  of  potassium  per- 
manganate 1  to  2,000  before  using  the  saline  irrigation. 

Sprays  of  adrenalin  (epinephrin)  of  varying  strengths  have  been 
advised  to  diminish  congestion  and  afford  relief.  I  have  been  disap- 
pointed in  their  results. 

Alcohol  diluted  six  or  eight  times  used  as  a  gargle  is  said  to  be  of  value. 

Touching  small  gangrenous  patches  with  tincture  of  iodine  has  been 
mentioned  as  helpful. 

Application  of  Lbffler's  solution  once  or  twice  a  day  is  a  method  long 
pursued. 

(Loffler's  Solution.  Menthol  10;  solve  in  toluol  ad  36  c.c.,  alcohol 
absolut.  60  c.c.,  Liq.  ferri  chlor.  4  c.c.) 

I  purposely  refrain  from  mentioning  many  escharotics  that  have 
been  advised,  as  I  believe  their  use  is  fraught  with  danger. 


402  TREATMENT  OF  ACUTE  INFECTIOUS  DISEASES 

Nose.  Here  again  cleanliness  is  the  purpose  of  the  measures 
used  and  here  even  more  gentleness  than  in  the  care  of  the  throat  must 
be  exercised.  The  best  solution  is,  as  in  the  throat,  physiological  salt 
solution  or  2  per  cent,  boric  acid  solution , or  a  Dobell's  solution  diluted 
two  to  four  times. 

Irrigation,  so  valuable  a  measure  in  the  care  of  the  throat,  is  to  be 
deprecated  as  a  routine  in  the  nose,  because  of  the  ease  with  which  the 
irrigation  fluid  runs  into  the  Eustachian  tube,  carrying  with  it  infection 
to  set  up  otitis  media  and  its  sequelae. 

The  spray  is  the  best  vehicle  here  and,  about  the  anterior  nares, 
most  gentle  swabbing. 

When  membrane  is  present  a  solution  of  hydrogen  dioxide  diluted 
three  or  four  times  may  be  applied  or  sprayed  before  the  cleansing 
spray. 

If  the  condition  of  the  nasal  passages  is  such  as  to  make  imperative 
other  measures  than  the  spray,  e.  g.,  in  young  children  with  profuse 
persistent  discharge,  the  irrigation  may  be  adopted  with  extreme  pre- 
cautions. One  uses  the  same  cleansing  solutions  mentioned,  directs  the 
patient  to  keep  the  mouth  open  during  the  whole  procedure,  which 
lessens  the  danger  of  forcing  fluid  into  the  tubes,  begins  on  the  side  the 
more  obstructed  to  avoid  damming  back,  holds  the  irrigator  at  the  least 
height  to  just  make  the  fluid  pass  through,  and  uses  a  glass  nasal  tip  or  a 
soft  rubber  catheter  with  multiple  holes  cut  in  it.  Once  in  four  to  six 
hours  is  often  enough. 

So  good  an  authority  as  McCollom  advises  in  membranous  rhinitis 
insufflations  of  calomel. 

A  muco-purulent,  sero-purulent  or  serous  rhinitis  occurs  in  10 
per  cent,  to  20  per  cent,  of  the  cases.  The  turbinates  are  cedematous, 
the  discharges  acrid  and  excoriating.  In  the  majority  of  the  cases  it 
developes  in  convalescence,  when  otherwise  the  patient  is  considered 
cured.  Its  secretions  are  highly  infectious  and  responsible  for  many 
return  cases.  The  measures  of  cleanliness  mentioned  above  are  used, 
but  recent  work  with  vaccine  therapy  gives  encouraging  results.  The 
staphylococcus  aureus  is  present  in  the  vast  majority  of  the  cases.  From 
cultures  of  it  and  other  organisms  present  an  autogenous  vaccine  may 
be  made,  or  in  the  absence  of  these  facilities  the  stock  staphylococcus 
vaccine  or  bacterin  may  be  used.  The  initial  dose  is  50,000,000  to 
100,000,000,  according  to  age  and  condition.  The  doses  may  be  given 
twice  a  week  or  every  fifth  or  sixth  day.  Usually  three  injections  suffice 
for  a  cure.  Slight  febrile  reactions  may  be  anticipated. 

No  doubt  the  sinuses  are  often  involved  and  a  persistent  temperature 
in  the  absence  of  obvious  cause,  such  as  the  ear,  should  make  one  think  of 


SCARLET  FEVER  403 

the  maxillary,  ethmoid  and  even  the  frontal  and  sphenoidal  sinuses,  in 
spite  of  the  late  development  of  these  sinuses  in  the  child. 

Cardio-Vascular  Apparatus.  There  has  been  much  discussion 
about  the  relative  parts  played  by  the  heart  and  vaso-motor  mechanism 
in  circulatory  failure.  I  interpret  the  results  of  such  discussions  and 
experiments  as  follows:  that  while  the  myocardium  may  be  the  seat  of 
parenchymatous  or  interstitial  change,  such  lesions  are  relatively  rare 
and  as  the  cause  of  death  extremely  rare.  That  circulatory  failure  may 
be  considered  as  practically  always  due  to  vaso-motor  failure  and  that 
the  result  of  experimentation  points  to  the  vaso-motor  center  as  the 
particular  part  of  the  apparatus  at  fault. 

In  one  group  of  cases  the  heart  sounds  may  be  clear  and  strong  to  the 
end,  bespeaking  competency  on  the  part  of  that  organ,  when  the  vaso- 
motor  center  has  been  so  impaired  as  to  make  the  cardiac  effort  futile. 
Pallor,  cold  extremities,  a  small,  empty  rapid  pulse  with  a  low  blood 
pressure  bespeak  the  condition.  In  another  group,  the  first  sound  of  the 
heart  may  be  muffled  or  almost  disappear,  or  may  be  split;  the  pulmo- 
nary second  sound  may  be  split  and  accentuated;  there  may  develop  a 
systolic  murmur  at  the  apex  and  the  heart  may  show  a  tachycardia, 
bradycardia  or  arythmia.  Yet  these  signs  may  not  mean  and,  in  the 
great  majority  of  cases  do  not  mean,  any  intrinsic  change  in  the  heart 
structure  or  its  functional  capacity,  but  may  be  explained  by  that  same 
loss  of  tone  that  obtains  in  the  vascular  system,  and  the  murmur  be  one 
or  relative  insufficiency  of  the  auriculo-ventricular  valves,  from  relaxa- 
tion of  the  rings. 

In  hearts  in  which  loss  of  tone  occurs,  the  unsupported  thin  conus 
arteriosus  feels  the  effect  most  markedly  and  its  contact  with  the  chest 
wall  immediately  overlying  at  the  second  left  intercostal  space  gives 
occasion  to  the  murmur. 

Very  slight  dilatation  may  sometimes  be  made  out  and  in  the  area  of 
the  conus  denote  its  dilatation.  The  apparent  impairment  of  cardiac 
action  is  due  to  loss  of  normal  resistance  ahead  in  the  dilated  peripheral 
vessels. 

Theoretically,  then,  our  attention  should  be  directed  to  the  vaso- 
motor  system  in  particular. 

It  is  our  misfortune  that  we  have  no  drug  that  can  do  for  the  vaso- 
motor  system  what  digitalis  does  for  the  heart. 

The  drugs  credited  with  effects  upon  the  vaso-motors  are  caffeine, 
camphor,  strychnine  and  adrenalin.  . 

None  of  these  are  as  reliable  as  we  could  wish,  all  are  evanescent 
in  their  effects,  necessitating  frequent  dosage  and  to  each  is  denied  by 
many  competent  men  the  effect  credited  to  it,  if  we  except  adrenalin. 


404  TREATMENT  OF  ACUTE  INFECTIOUS  DISEASES 

Digitalis.  But  let  us  suppose  that  there  is  no  improvement  in 
the  circulatory  condition  in  response  to  these  measures.  Shall  we  use 
digitalis?  I  should  say  decidedly  yes.  It  may  be  objected  first,  that  if 
the  heart  is  not  impaired  it  is  questionable  whether  digitalis  can  enhance 
its  functions;  but  even  though  the  chances  of  its  impairment  are  statis- 
tically small,  there  is  still  the  possibility  that  it  is  to  some  degree  and  may 
be  helped  by  digitalis;  second,  that  its  effect  on  blood  pressure  through 
its  action  on  the  vaso-motor  apparatus  in  man  is  in  doubt,  but  still  that 
it  has  such  an  action  in  animal  experimentation  is  accepted,  and  the 
benefit  of  the  doubt  should  be  given  in  serious  cases;  third,  that  its  effect 
on  the  heart  is  lessened  in  fever,  e.  g.,  the  inhibitory  action  of  the  vagus 
enhanced  by  the  drug  may  be  set  aside  in  fever,  because  under  the  influ- 
ence of  the  toxins,  the  inhibitory  action  is  said  to  be  lost  in  part  or  whole. 

I  question  the  accuracy  of  this  statement;  for  I  have  repeatedly  slowed 
the  heart  in  fever  by  sufficient  doses  of  digitalis;  moreover,  we  now  have 
electrocardiographic  evidence  ef  the  pharmacological  effect  of  the  drug  on 
the  heart  in  acute  infectious  diseases.  In  the  presence  of  so  much  doubt 
our  anticipations  must  be  tempered,  but  it  seems  to  me  that  any  drug 
which  under  other  circumstances  has  so  decided  an  effect  to  improve  a 
faltering  circulation,  should  not  be  left  untried  because  of  theoretical 
considerations. 

Whatever  the  cause  may  be  of  circulatory  collapse  in  acute  infectious 
disease  and  however  digitalis  may  operate  in  this  condition  it  is  my  con- 
viction strengthened  by  a  considerable  experience  that  this  drug  and  its 
pharmacological  equivalent  strophanthin  are  the  only  reliable  agents 
applicable  to  the  condition. 

The  action  of  digitalis  is  slow,  however  administered,  and  if  we  are 
accepting  it  as  an  agent  to  be  used,  it  must  be  begun  before  the  condition 
has  become  dire.  I  feel  that  it  may  well  be  begun  when  frank  evidences 
of  failing  circulation  set  in  as  an  adjuvant  to  the  vaso-motor  stimulants 
mentioned. 

The  dose  in  an  adult  should  be  5ss.  (15  c.c.)  of  the  infusion  three  times 
a  day  or  four  times  a  day;  that  is,  the  equivalent  of  10  1/2  to  14  grains 
(0.66  to  1  Gm.)  a  day.  Any  official  preparation  may  be  used  in  equiva- 
lent doses.  It  must  always  be  prepared  fresh  from  a  fresh  green  leaf. 
Such  doses  may  be  kept  up  for  12  to  15  doses. 

For  very  rapid  effects,  strophanthin  may  be  used  in  doses  of  gr.  1/120 
(0.0005  Gm.)  into  muscle  or  vein,  with  the  anticipation  of  a  digitalis 
effect  beginning  within  the  hour.  Such  doses  should  not  be  repeated 
except  with  caution,  in  less  than  twelve  hours.  Digitalis  may  be  begun 
at  once  in  the  above  doses,  as  its  effects  will  be  delayed  for  some  thirty- 
six  hours. 


SCARLET  FEVER  405 

For  the  child  of  five  years  give  about  one-quarter  this  dose  of  digitalis 
or  strophanthin. 

A  more  elaborate  discussion  of  and  more  detailed  instructions  for 
the  use  of  digitalis  in  any  acute  infectious  disease  will  be  found  under 
pneumonia  (Chap.  IX). 

Caffeine  may  be  used  if  digitalis  fails.  I  am  a  little  loath 
to  use  it  when  large  doses  of  digitalis  have  been  given,  as  I  think  there 
is  an  incompatability  between  the  drugs,  at  least  in  some  individuals, 
including  rapid  heart,  dyspnoea  and  alarming  evidences  of  circulatory 
insufficiency.  I  advise  then  that  small  doses  be  administered  tentatively 
at  first  to  assure  oneself  that  no  such  incompatibility  exists.  Its  ac- 
tion is  complicated  and  not  constant  in  effect.  I  quote  the  authority 
of  Meyer  and  Gottlieb's  Experimental  Pharmacology  as  an  explanation 
for  both  these  statements.  Its  action,  they  say,  is  a  combination  of  the 
following  factors:  "1.  Stimulation  of  the  vaso-motor  centers:  Con- 
striction of  the  arterioles  and  as  a  consequence  under  certain  circum- 
stances a  rise  of  blood  pressure.  2.  Effects  upon  the  heart  in  a  multi- 
fold manner:  (a)  Stimulation  of  the  cardiac  inhibitory  vagus  centers; 
Slowing  of  the  pulse,  (b)  Stimulation  of  the  peripheral  accelerating 
cardiac  ganglia:  Quickening  of  the  pulse  rate;  according  to  the  circum- 
stances and  to  individual  factors  the  one  or  the  other  action  predomi- 
nates, (c)  A  change  of  the  heart  muscle,  whose  diastolic  capacity  de- 
creases and  whose  systolic  energy  increases:  as  a  consequence,  there  is 
usually  a  diminution  of  output  per  beat  and  lessening  of  blood  pressure, 
(d)  Dilatation  of  the  coronary  vessels. 

"If  the  vascular  contraction  dominates,  the  result  will  be  a  rise  of 
blood  pressure  above  the  norm;  but  if  the  vaso-constrictor  centers  are 
but  little  excitable  or  paralysed  through  some  pharmacological  agent, 
like  alcohol,  then  caffeine  will  bring  a  fall  in  the  blood  pressure  as  a  rule." 

In  man,  in  moderate  doses,  a  slowing  of  the  pulse  ensues  with  a  dimin- 
ished output  per  unit  of  time.  It  is  only  the  effect  on  the  vaso-motor 
centers  that  dominate  the  blood  pressure  that  justifies  its  use.  This 
effect  is  brought  about  through  the  splanchnic  vessels.  Many  other 
territories,  such  as  the  renal  vessels  and  coronaries  are  dilated.  (Soil- 
man.) 

Caffeine  is  best  given  in  the  form  of  one  of  the  soluble  double  salts 
of  sodium  benzoate  and  caffeine  or  sodium  salicylate  and  caffeine.  It 
should  be  given  hypodermically  or  for  more  rapid  action,  intramus- 
cularly, in  doses  of  gr.  iii  to  gr.  v  (0.2  to  0.33  Gm.) ;  this  is  equal  to  about 
half  the  amount  of  pure  caffeine.  In  a  child  of  five  years  gr.  ss.-i  (0.030- 
0.060  Gm.);  at  ten  years  gr.  i-ii  (0.060-0.120  Gm).  It  should  be  re- 
peated at  two-hour  intervals  in  urgent  cases,  for  the  effect  rarely  lasts 


406  TREATMENT  OF  ACUTE  INFECTIOUS  DISEASES 

beyond  this  period.  One  may  anticipate  an  effect  within  five  minutes, 
arriving  at  a  maximum  within  the  half  hour  and  amounting  to  10  to 
20  mm.  Hg.  It  may  last  two  hours,  but  in  my  observations  often  a  much 
less  time. 

Camphor.  This  is  less  reliable  than  caffeine,  but  is  my  second 
choice.  It  should  be  given  in  doses  of  gr.  iii  to  gr.  v  (Ot20-0.30  Gm.) 
in  the  adult  and  gr.  ss.  to  i  (0.030-0.060  Gm.)  in  a  child  of  five  years, 
and  gr.  i  to  ii  (0.060-0.120  Gm.)  at  ten  years.  It  is  best  given  in  a 
solution  of  10  to  20  per  cent,  in  olive  or  sesame  oil,  or  in  10  per  cent  of 
ether  hypodermically  or  intramuscularly  and  should  be  repeated  every 
two  hours  in  urgent  cases.  One  should  never  use  camphor  put  up  in  par- 
affin (mineral  oil)  as  extensive  necrosis  of  tissues  have  followed  upon  its 
administration.  The  results  when  they  are  positive  are  in  my  observa- 
tions very  like  those  of  caffeine,  a  rise  of  pressure  in  a  few  minutes, 
reaching  a  maximum  within  the  half  hour  to  10  to  20  mm.  Hg.  and 
lasting  from  forty-five  minutes  to  over  an  hour. 

One  may  alternate  these  drugs,  each  every  four  hours,  thus  one  or 
the  other  every  two  hours. 

Strychnine  is  the  third  choice.  It  should  be  given  as  sulphate 
in  doses  of  gr.  1/60  to  gr.  1/30  (0.001-0.002  Gm.)  every  three  hours  in 
the  adult  and  in  doses  of  gr.  1/200  to  gr.  1/150  (0.0003-0.00045  Gm.) 
at  five  years  and  double  this  dose  at  ten  years.  Personally,  I  place  but 
little  reliance  on  this  drug. 

Adrenalin  (Epinephrin)  is  not  appropriate  for  continued  dose. 
Its  effects  are  prompt  and  evanescent.  It  has  value  in  sudden  collapse 
and  acts  on  the  vessels  themselves,  when  the  center  cannot  respond  to 
stimulation.  Its  effects  vary  with  the  mode  of  administration. 

In  my  studies  I  have  seen  no  effects  when  given  by  mouth  or  rectum. 
The  effect  is  uncertain  under  the  skin;  it  may  be  decided  and  prompt 
or  much  delayed  and  slight  or  fail.  It  is  more  certain  when  given  into 
the  muscle  and  most  certain  by  the  vein.  The  dose  by  the  skin  is  m. 
x  (0.65  c.c.)  of  1:1000  solution;  by  the  muscle  slightly  less;  as  an  initial 
dose  m.  vii  or  viii  (0.5  c.c.).  By  the  vein  m.  ii  or  iii  (0.120-0.2  c.c.). 
This  is  the  dose  for  an  adult.  For  the  child  of  five  years  one-quarter 
the  dose,  at  ten  years  or  twelve  years  one-half. 

There  is  danger  in  the  careless  handling  of  this  drug  and  more  es- 
pecially in  the  presence  of  a  weak  heart.  I  have  seen  in  an  adult,  mori- 
bund, a  dose  of  m.  vii  (0.5  c.c.)  into  the  vein  shoot  a  pressure  of  60  to 
70  mm.  to  230  mm.  faster  than  it  could  be  taken.  Such  strains  on  the 
heart  may  cause  a  failure  on  the  part  of  that  organ. 

Alcohol  I  believe  to  be  a  depressant  and  condemn. 

Cold  in  the  shape  of  packs  or  cold  air  with  proper  precautions 


SCARLET  FEVER  407 

of  bed  making  have  excellent  results  on  the  circulation.  See  Open  Air 
Treatment.  (Pneumonia,  Chap.  IX.) 

Nervous  Symptoms.  These  depend  upon  the  severity  of  the 
attack.  In  moderate  grades  of  the  infection  there  may  be  some  stupor, 
but  in  the  more  severe,  delirium  of  the  active  type  or  a  low  muttering 
delirium. 

There  is  nothing  better  for  the  cerebral  manifestations  of  the  tox- 
emia than  cold  water  as  described  under  the  treatment  of  hyperpy- 
rexia,  in  the  shape  of  packs,  sponges  or  baths. 

An  ice-cap  applied  to  the  head  has  a  sedative  effect. 

If  there  is  much  restlessness  bromides  may  be  used,  gr.  iii  (0.20  Gm.) 
to  gr.  v  (0.30  Gm.)  three  or  four  times  a  day  in  children,  gr.  xv  to  gr. 
xx  (1-1.30  Gm.)  in  adults.  Sodium,  or  potassium  salts  may  be  used 
or  equal  parts  of  sodium,  potassium  and  ammonium. 

Small  doses  of  acetphenetidin  (phenacetin) ,  gr.  i  to  gr.  ii  (0.060-0.120 
Gm.)  at  four-hour  intervals  may  be  given  to  children,  but  the  temptation 
to  use  drugs  instead  of  such  measures  as  hydrotherapy  must  be  com- 
bated. 

Sleeplessness.  For  milder  grades  the  effects  of  the  baths  are 
often  sufficient.  Instead  of  the  cold  bath,  sponging  with  warm  water 
may  prove  more  sedative. 

The  small  doses  of  bromides  or  acetphenetidin  (phenacetin)  advised 
may  prove  effectual.  In  adults,  trional,  gr.  x  to  gr.  xv  (0.60-1  Gm.) 
to  be  repeated  in  two  or  three  hours,  if  necessary,  or  chloralamid,  gr. 
xx  to  gr.  xxx  (1.30-2  Gm.)  to  be  repeated  in  the  same  tune  if  not  effectual. 

For  wild  delirium,  sacrificing  sleep  and  rest  and  imperiling  the  patient 
by  the  exhausion  provoked  morphine  sulphate  must  be  given,  in  the 
smallest  dose  effectual.  In  the  adult  gr.  1/8  (0.008  Gm.)  hypoder- 
mically  to  be  repeated  in  two  or  three  hours  if  needed,  in  the  child  of 
six,  gr.  1/48  to  gr.  1/24  (0.0015-0.003  Gm.) 

SERUM  AND  VACCINE  THERAPY 

The  achievements  of  modern  medicine  in  serum  and  vaccine  ther- 
apy naturally  turn  our  minds  to  these  fields  in  the  consideration  of  so 
dire  a  malady  as  scarlet  fever.  As  yet  neither  of  these  methods  have 
yielded  satisfactory  results  in  this  disease.  This  will  be  readily  under- 
stood when  we  consider  that  the  causative  agent  of  scarlet  fever  is  not 
yet  known  and  that  streptococcic  infections  during  the  acute  stage  are 
but  little  amenable  to  vaccines.  With  regard  to  vaccines  we  may  quote 
the  statement  of  Weaver  in  Musser  and  Kelly's  Practical  Treatment 
that  after  a  considerable  experience  with  vaccines  he  concludes  that 


408  TREATMENT  OF  ACUTE  INFECTIOUS  DISEASES 

their  use  early  in  scarlet  fever  does  not  stay  the  usual  complications 
but  that  they  are  useful  in  the  treatment  of  the  subacute  and  chronic 
stages  of  some  of  the  streptococcus  complications  of  the  disease. 

Immune  Human  Serum,  however,  gives  a  more  hopeful  out- 
look; it  is  derived  from  patients  recently  convalescent  from  the  disease 
and  is  presumed  to  contain  antibodies  against  the  scarlet  fever  virus 
and  streptococci  that  have  been  associated  with  it. 

While  statistics  so  far  accumulated  are  inadequate  from  which  to 
draw  definite  conclusions  the  workers  have  been  competent  and  care- 
ful observers  and  their  convictions  are  worthy  of  serious  consideration. 

The  serum  is  obtained  by  withdrawing  blood  from  patients  in  con- 
valescence during  the  fourth  week.  Patients  who  have  been  septic 
are  excluded  and  care  taken  to  determine  each  donor  free  from  tubercu- 
losis. The  serum  is  tested  for  syphilis,  and  its  sterility  determined. 
Serum  from  several  patients  is  pooled,  as  the  antibody  content  of 
individuals  vary  and  we  have  no  way  of  determining  that  content; 
this  is  stored  in  an  ice  box.  The  modes  of  administration  are  by  the 
vein  as  practiced  by  Reiss  and  Jungman  in  amounts  to  40  to  100  c.c., 
following  the  technique  given  under  pneumonia,  Chap.  IX.  Emphasis 
must  be  laid  on  the  increased  efficacy  of  early  administration.  Weaver, 
more  recently,  following  the  same  details  of  preparation,  preferred  the 
intramuscular  route,  giving  an  average  dose  of  60  c.c.  into  the  muscles 
of  the  outer  side  of  the  thigh.  He  divided  the  dose  between  the  sides. 
Usually  one  dose  sufficed,  but  in  a  few  a  second  was  given. 

Personally  I  should  prefer  the  intravenous  route  if  the  vein  can  be 
readily  entered;  but  if  the  results  are  as  satisfactory  as  they  are  re- 
ported to  be  by  the  intramuscular  route,  one  can  readily  appreciate  how 
this  method  would  come  into  more  general  usage. 

Zingher  made  use  of  the  whole  blood  withdrawn  in  the  second  and 
third  weeks  of  convalescence  instead  of  the  serum.  He  withdrew  blood 
from  the  veins  at  the  bend  of  the  elbow,  citrated  at  once  with  1  c.c.  of 
10  per  cent,  sodium  citrate  to  each  30  c.c.  of  blood  and  introduced  this 
fresh  blood  in  doses  of  70  to  240  c.c.  distributed  among  several  large 
muscle  masses.  This  blood  even  kept  in  the  ice  box  deteriorates  after 
one  to  two  months.  All  of  these  investigators  seem  equally  enthusiastic. 
The  best  results,  of  course,  are  in  those  who  are  toxic,  not  septic.  There 
is  a  prompt  fall  of  temperature.  In  the  toxic  cases  this  fall  is  likely  to  be 
permanent,  in  the  septic  cases  to  be  followed  by  a  secondary  rise.  The 
fall  begins  about  2-4  hours  after  the  injection  and  reaches  its  maximum 
in  12  to  24  hours.  Accompanying  this  are  amelioration  of  the  general 
condition,  lessening  of  cyanosis,  diminution  or  disappearance  of  delirium 
and  change  in  the  appearance  of  the  patient.  Even  septic  cases  show 


SCARLET  FEVER  499 

improvement  if  the  serum  is  used  early  and  the  recurring  temperature 
is  usually  less  high  and  the  course  seems  to  be  shortened,  but  if  adminis- 
tered late,  in  septic  cases,  no  good  results  ensue. 

Normal  Human  Blood.  Zingher,  however,  says  that  even  in  the 
late  septic  cases,  with  extensive  throat  exudate,  higher  septic  tem- 
perature, poor  circulation,  dusky  skin,  often  with  running  ears  and  en- 
larged cervical  glands  the  use  of  fresh  normal  citrated  blood  is  followed 
by  a  definite  beneficial  effect  in  some  desperately  ill  patients.  His  doses 
are  4  oz.  up  to  4  years  and  6  to  8  oz.  in  older  children  and  adults,  which 
may  be  repeated  at  intervals  of  4  to  5  days  if  needed.  This  is  given  into 
the  muscles. 

The  general  practitioner,  unless  he  has  ready  access  to  a  scarlet  fever 
service  will  probably  still  delay  the  use  of  serum  to  the  late  case  of  which 
he  despairs.  He  should  keep  this  method  in  mind  in  all  cases  that  appear 
severe  at  the  onset. 

A  polyvalent  streptococcus  serum,  in  the  production  of  which  some 
thirty  types  of  streptococci  obtained  from  scarlet  fever  cases  have  been 
used  has  been  tried  in  the  Annaskinderspital  in  Vienna  since  1902  with 
gratifying  results.  This  is  known  as  the  Moser  serum. 

The  statistics  in  this  hospital  are  quoted  as  8  per  cent,  against  13  per 
cent,  in  the  other  hospitals  of  the  city.  Such  results  would  seem  ex- 
tremely satisfactory,  for  the  gain  must  logically  be  attributed  to  the 
successful  combating  of  the  streptococcus  toxemia.  The  Moser  serum 
has  never  been  obtainable  in  this  country,  which  is  regrettable  consider- 
ing the  long  and  satisfactory  usage  in  so  reliable  a  service. 

In  this  country  a  polyvalent  serum  from  different  sources  has  been 
used,  e.  g.,  that  of  the  New  York  Board  of  Health. 

Personally,  I  am  inclined  to  use  the  polyvalent  serum  from  such 
reliable  sources,  because,  in  the  absence  of  any  known  harm,  I  feel,  in 
desperate  cases,  the  patient  should  be  given  the  benefit  of  the  doubt. 

The  quantity  used  depends  on  the  make  and  is  specified  in  each  in- 
stance. 

Otitis.  So  frequent  a  complication  is  otitis  in  scarlet  fever  that 
the  possibility  of  its  onset  should  not  be  forgotten  from  the  day  the  case 
is  taken  in  hand.  The  frequency  varies  in  different  epidemics  and  has 
decided  relation  to  the  severity  of  the  throat  symptoms.  In  large  bodies 
of  statistics  the  incidence  of  the  complication  has  been  set  at  figures 
varying  from  10  per  cent,  to  33  per  cent.,  while  in  cases  that  may  be 
termed  severe  the  percentage  runs  to  50  per  cent,  and  75  per  cent. 

It  should  be  laid  down  as  a  cardinal  rule  that  the  ears  should  be 
examined  daily  with  the  otoscope.  Few  simple  procedures  repay  the 
effort  expended  on  them  comparable  to  otoscopy.  The  small  size  of 


410  TREATMENT  OF  ACUTE  INFECTIOUS  DISEASES 

the  auditory  canal  in  the  little  patients  and  the  difficulty  of  determining 
landmarks  discourage  many  practitioners  in  making  the  effort.  Of  very 
great  assistance  are  the  magnifying  otoscopes  with  electric  light  attach- 
ment, easily  portable  with  a  small  batteryv  These  instruments  bring  out 
the  field  with  remarkable  distinctness. 

This  examination  becomes  the  more  imperative  when  one  appreciates 
that  the  condition  may  occur  without  pain  and  the  first  premonition 
of  its  existence  be  determined  by  a  discharge.  Before  this  discharge 
appears,  however,  opportunity  for  a  spread  into  adjacent  structures  has 
been  given  and  the  rupture  of  the  drum  may  sacrifice  the  integrity  of 
that  structure  beyond  repair.  Again,  patients  who  are  very  ill  or  who 
are  delirious  may  not  voice  the  pain  and  discomfort  they  feel  and  thus 
give  no  clue  to  the  condition. 

As  a  prophylactic  measure  I  would  reiterate  the  warning  given  in 
considering  the  care  of  the  nasal  passages,  that  irrigation  may  induce 
the  otitis  and  if  the  state  of  the  nasal  passages  seem  to  demand  the  use  of 
an  irrigation,  it  must  be  done  with  extreme  care  and  with  the  patient's 
mouth  open. 

With  appearance  of  bulging  of  the  drum,  congestion  and  reddening 
of  the  drum,  a  loss  of  lustre  and  macerated  appearance  of  the  drum,  an 
incision  is  indicated.  To  the  general  practitioner  a  detailed  description 
of  the  drum  appearances  that  do  or  do  not  indicate  paracentesis  is  often 
confusing.  It  seems  to  me  that  a  decided  deviation  from  the  normal  in 
the  appearance  of  the  drum  and  especially  if  accompanied  by  pain  in 
the  ear  and  a  rise  of  temperature  ought,  in  a  disease  in  which  the  sequelae 
of  otitis  are  so  serious,  to  demand  immediate  interference. 

Technique.  The  external  auditory  canal  should  be  cleansed  first 
with  cotton  on  an  applicator  with  1  to  1,000  bichloride.  A  curved 
bistory  or  a  paracentesis  knife  is  used.  The  incision  should  begin  pos- 
teriorly and  below  at  the  end  of  the  malleus,  sweep  upward  along  the  edge 
of  the  drum  to  Shrapnell's  membrane,  through  it  and  out  along  the  upper 
and  posterior  wall.  Do  not  use  wicks  and  drains  or  pack  the  canal  tight 
with  cotton. 

Irrigations  should  be  instituted  every  2  hours  by  day  and  every 
4  hours  by  night  with  1  to  5,000  bichloride  of  mercury  or  with  boric  acid 
solution,  2  per  cent,  to  4  per  cent.  A  pint  should  be  used,  from  an  irri- 
gator  or  fountain  syringe  held  2  to  2  1/2  feet  above  the  level  of  the  ear 
As  the  ear  improves,  the  frequency  may  be  decreased  to  every  4  or  6 
or  8  hours. 

In  irrigating  a  child's  ear  the  ear  should  be  drawn  down  and  back; 
in  an  adult  up  and  back. 

With  a  skilled  hand  the  pain  is  but  momentary  though  intense;  a 


i 


SCARLET  FEVER  411 

whiff  of  chloroform  or  ether  may  be  given  or  ethyl  chloride  and  the  inci- 
sion done  during  the  primary  stages  of  anaesthesia. 

For  the  pain  of  earache,  dry  heat  is  the  best  application.  This  may 
be  afforded  in  the  shape  of  a  hot  salt-bag,  a  hot  water  bottle  or  hot 
plate.  Irrigations  and  instillation  are 'to  be  deprecated,  because  the 
maceration  ensuing  blinds  the  landmarks  and  makes  both  the  examina- 
tion and  incision  more  difficult.  If,  however,  the  pain  is  not  relieved  in 
this  manner,  one  may  try  a  device  advised  by  Yeo.  Heat  a  large  sized 
wine-glass  with  hot  water;  pour  this  out  and  then  into  the  hot  glass 
place  a  pledget  of  cotton,  pouring  on  this  10  to  20  drops  of  chloroform 
and  then  apply  the  whole  closely  over  the  ear,  or  phenol  (carbolic)  in 
glycerin  5  per  cent.  gtt.  ii-iii. 

If  irrigations  must  be  used,  use  first  simple  hot  water,  then  4  per  cent, 
cocaine  hydrochloride. 

The  natural  course  of  the  discharge  in  older  children  and  adults  is  one 
to  two  weeks,  but  much  longer  in  young  children.  In  these,  however, 
it  usually  ceases  within  twelve  weeks. 

After  the  drum  is  incised,  a  cessation  of  discharge  with  a  rise  of  tem- 
perature, pain  over  the  mastoid  or  swelling  there  denotes  an  implication 
of  that  structure;  but  swelling  may  be  absent,  pain  or  tenderness  slight 
and  the  discharge  profuse  and  yet  the  mastoid  involved.  A  rise  of  tem- 
perature, not  otherwise  accounted  for,  should  lead  to  strong  suspicions 
of  the  mastoid  and  surgical  advice  and  interference  sought.  Involve- 
ment of  the  sinus,  of  the  meninges  and  the  brain  are  all  possibilities  that 
keep  us  awake  to  the  slightest  signs  of  the  same  with  a  view  to  expert 
opinion  and  surgical  intervention. 

It  must  be  remembered  that  these  discharges  are  highly  infectious 
and  should  be  treated  with  1  to  20  carbolic  or  1  to  1,000  bichloride  and 
what  can  be  burned  should  so  be  disposed  of. 

Vaccines.  The  very  fact  that  these  discharges  are  so  infectious; 
that  they  detain  the  patient  in  the  hospital  so  long;  that  in  the  end  a 
small  per  cent,  must  be  released  on  the  supposition  that  the  discharges 
are  no  longer  infectious,  only  to  demonstrate  that  the  supposition  is  not 
always  correct  makes  any  treatment  that  has  theoretical  promise  wel- 
come. 

Good  evidence  is  forthcoming  that  the  recently  developed  vaccine 
therapy  is  fulfilling  this  theoretical  promise  to  some  degree.  This  is  not 
the  place  to  cite  the  literature  at  length  on  the  subject,  but  an  extremely 
instructive  consideration  of  this  subject  will  be  found  in  an  article  in  the 
Journal  of  the  A.M.  A.,  April  11,  1911,  by  Weston  and  Kolmer,  entitled 
"The  Treatment  of  Suppurative  Otitis  Media  (Scarlatinal)  by  Bacterial 
Vaccines  (Bacterines)."  Their  conclusions  were  "that  the  best  time,  all 


412  TREATMENT  OF  ACUTE  INFECTIOUS  DISEASES 

things  considered,  for  commencing  vaccine  treatment  in  cases  of  otitis 
media,  is  from  the  eighth  to  the  sixteenth  day  of  the  discharge,"  thus 
agreeing  with  nearly  all  observers,  that  the  subacute  stage  is  that  in 
which  the  most  favorable  results  ensue.  "That  continued  high  fever, 
nephritis,  toxemia  and  various  intercurrent  affections  are  contra-indica- 
tions  to  the  administration  of  vaccines."  "That  under  yaccine  treat- 
ment, three  times  as  many  patients  are  cured  within  thirty  days  and 
permitted  to  go  home  as  under  the  usual  treatment.  This  means  that 
the  average  residence  of  the  patient  in  the  hospital  has  been  considerably 
reduced." 

The  organisms  most  commonly  met  are  staphylococcus  aureus  and 
albus,  bacillus  pseudodiphtherise,  streptococcus  pyogenes  and  bacillus 
pyocyaneus. 

The  vaccine  should  be  autogenous  and  one  finds  that  recultures  do 
not  always  show  the  same  organism  or  show  additional  organisms.  The 
staphylococcus  is  often  found  early,  a  week  later  the  bacillus  pseudodiph- 
therise often  intrudes  and  as  a  still  later  comer,  as  in  many  suppurative 
conditions,  appears  the  bacillus  pyocyaneus;  hence,  the  value  of  recul- 
tures and  fresh  vaccines.  The  initial  dose  depends  on  the  organism, 
being  small  with  the  streptococcus,  5,000,000  to  10,000,000,  larger  with 
the  staphylococcus,  20,000,000  to  50,000,000,  and  a  little  more  with  the 
others  mentioned.  The  doses  should  be  administered  twice  a  week  or 
every  5  or  6  days.  The  increase  depends  on  the  reaction.  The  reaction 
is  (1)  general,  a  slight  fever.  (2)  Local;  an  increase  in  the  discharge. 
(3)  With  some  organisms,  such  as  the  streptococcus,  a  local  redness  at 
the  site  of  injection.  It  is  desired  to  increase  the  dose  so  that  little  or  no 
reaction  occurs. 

The  ear  should  not  be  syringed  or  medicated  during  the  treatment, 
as,  in  the  lighting  up  of  the  process,  as  a  part  of  the  reaction,  a  spread 
into  adjacent  structures  is  facilitated  by  the  syringing. 

The  most  cases  are  cured  within  five  or  six  doses;  a  few  may  require 
a  dozen  and  a  very  few  more. 

Adenitis.  A  certain  amount  of  involvement  of  the  lymphatic 
glands  always  occurs  and  especially  of  the  cervical  glands. 

When  the  angina  is  severe  the  adenitis  may  be  very  marked.  Usually, 
however,  this  inflammation  of  the  gland  that  occurs  at  the  height  of 
the  fever  subsides  without  suppurating.  Curiously  enough  the  serious 
involvement  of  the  glands  is  a  late  manifestation,  occurring  during  des- 
quamation,  most  commonly  in  the  third  or  fourth  week  or  even  later, 
and,  indeed,  may  occur  in  the  same  glands  which,  enlarged  during  the 
period  of  maximum  intoxication,  had  resolved.  Those  at  the  angle  of 
the  lower  jaw  are  particularly  affected.  It  is  this  adenitis  that  so  fre- 


SCARLET  FEVER  413 

quently  goes  on  to  suppuration.  Whenever  a  temperature  occurs  during 
convalescence  this  is  the  one  territory  the  involvement  of  which  must 
be  kept  in  mind. 

Cold.  The  best  application  to  be  made  at  once  is  cold  in  the 
shape  of  ice  in  the  ice-bag  or  bladder-skins.  There  should  be  a  layer 
of  flannel  between  the  ice  and  the  skin.  Direct  contact  or  too  long 
contact  may  damage  the  skin. 

While  remaining  skeptical  about  the  value  of  drugs  locally  applied, 
my  choice  is  for  ichthyol,  painted  on  pure  or  in  the  shape  of  a  25  per 
cent,  ointment. 

There  is  a  difference  of  opinion  about  the  value  of  hot  applications, 
such  as  poultices.  My  own  feeling  is  that  it  is  useless  and  looks  away 
from  good  surgical  practice. 

At  the  very  first  sign  of  suppuration,  incise. 

The  glands  may  not  suppurate,  but  become  gangrenous,  the  tissue 
overlying  breaking  down;  or  there  may  be  a  great  deal  of  periadenitis 
and  cellulitis  with  brawny  induration. 

There  is  a  difference  of  opinion  about  the  advisability  of  incision  in 
these  cases.  Such  brawny  masses  will  often  resolve,  but  if  the  toxemia 
is  increasing  and  the  process  spreading,  free  incision  into  the  tissue 
should  be  made. 

Arthritis.  An  arthritis,  a  so-called  scarlatinal  rheumatism,  occurs 
in  about  4  per  cent,  of  the  cases,  coming  on  as  a  rule  in  the  second  week 
of  the  attack.  In  the  majority  of  cases  it  may  be  classed  as  a  toxic 
arthritis;  in  rare  instances  it  is  a  septic  process. 

It  resembles  the  gonococcal  type  of  arthritis  rather  than  that  of  true 
rheumatism,  affecting  the  small  joints  of  the  fingers  and  wrists,  as  well 
as  the  large  ones.  There  is  as  a  rule  only  slight  swelling  and  redness; 
rarely  an  effusion  of  serum,  very  rarely  pus.  It  lasts  as  a  rule  only  three 
or  four  days,  exceptionally  a  week. 

It  may  be  treated  on  the  same  principles  as  the  arthritis  of  rheumatism 
(see  Rheumatic  Fever,  Chap.  Ill),  namely,  rest  to  the  joint,  by  splints 
or  other  devices,  pillows,  folded  blankets,  local  applications  of  ice,  or 
a  snug  bandage  if  there  is  effusion;  if  not,  methyl  salicylate  painted 
on  and  the  joint  wrapped  in  a  thick  layer  of  cotton  batten  and  the  inter- 
nal administration  of  sodium  salicylate  or  other  form  of  salicylate, 
such  as  acetyl  salicylic  acid  (aspirin),  salicin,  oil  of  wintergreen,  be 
begun  in  doses  of  gr.  v  to  viiss.  (0.33-050  Gm.)  every  two  hours  to 
a  child  of  ten  years  or  twelve  years,  half  the  dose  at  five  years,  and  gr. 
x  to  gr.  xv  (0.6&-1.0  Gm.)  hi  adults.  This  may  be  given  with  or  without 
alkaline  salts.1  If  with,  give  sodium  bicarbonate  in  double  the  doses 

1  Alkaline  salts  are  said  to  be  incompatible  with  acetyl  salicylic  acid  but  prob- 


414  TREATMENT  OF  ACUTE  INFECTIOUS  DISEASES 

of  the  salicylates,  until  the  urine  is  alkaline  and  then  diminish  the  dose 
gradually,  just  keeping  the  urine  alkaline. 

As  the  symptoms  subside  lessen  the  dose. 

If  the  joints  suppurate  they  must  be  treated  on  surgical  principles. 
Aspiration  under  surgical  precautions  should  determine  the  presence 
of  the  suspected  pus.  The  joint  may  then  be  aspirated  through  a  canula 
and  thoroughly  irrigated  with  sterile  salt  solution.  It  may  be  well  to 
inject  a  half  ounce  of  10  per  cent,  formalin  in  glycerin.  If  the  joint  does 
not  resolve  under  these  procedures  it  should  be  opened. 

Myositis  may  occur  instead  of  the  arthritis,  most  commonly  a  lum- 
bago. This  is  to  be  treated  locally  and  by  internal  medication  like  the 
arthritis. 

Nephritis.  Scarlatinal  nephritis  adds  much  to  the  dread  in 
which  scarlet  fever  is  held,  not  only  because  of  the  immediate  danger 
entailed  by  it,  but  also  because  of  the  haunting  possibility  of  the  in- 
sidious development  of  a  chronic  process,  it  may  be,  long  after  every 
indication  of  kidney  damage  has  passed  and  because  its'  onset  comes  at 
the  time  when  we  are  beginning  to  congratulate  ourselves  on  a  happy 
convalescence. 

Early  in  the  fever  a  slight  albuminuria,  such  as  one  may  get  in  any 
acute  infection,  from  acute  degenerative  processes  of  no  lasting  or  im- 
portant significance  in  the  parenchyma  occurs.  This  need  give  little 
alarm,  but  the  increase  of  albumin  at  the  height  of  the  disease  or  at  the 
beginning  of  the  third  week  or  the  beginning  of  the  fourth  has  a  differ- 
ent meaning. 

Delafield  describes  the  nephritis  occurring  at  the  height  of  the  disease 
as  an  acute  exudative  nephritis — (non-productive)  and  while  this  may 
prove  fatal,  if  it  does  not,  the  lesion  clears  up  entirely;  but  the  late 
nephritis,  post  scarlatinal,  he  says  is  an  acute  productive  nephritis, 
which,  if  not  fatal,  is  likely  to  go  over  into  a  chronic  nephritis  and  it  is 
this  feature  that  makes  this  late  nephritis  so  serious. 

Every  day  throughout  the  continuance  of  the  infection  and  even 
more  imperatively  throughout  the  convalescence  the  urine  should  be 
examined  for  albumin.  It  is  well  to  have  the  paraphernalia  for  the 
simple  heat  and  acetic  acid  or  the  cold  nitric  acid  test  in  the  sick  room 
or  bath-room  and  do  the  test  at  each  daily  visit. 

We  must  keep  in  mind,  too,  that  a  mild  attack  can  in  no  way  warrant 
the  assumption  that  nephritis  and  severe  nephritis  will  not  occur.  In 
fact,  there  seems  to  be  a  dissociation  in  the  degrees  of  severity  of  the 
attack  and  the  onset  of  the  nephritis. 

ably  small  doses  are  not  objectionable.    For  discussion  see  Acute  Rheumatic 
Fever,  Chap.  III. 


SCARLET  JFEVER  415 

We  know  that  the  severe  form  of  nephritis  is  most  common  in  the 
second  lustrum  and  that  the  appearance  of  albumin  in  children  after 
ten  is  more  likely  to  be  an  albuminuria  simply;  hence,  redoubled  vigi- 
lance in  the  younger  children. 

Nephritis  is  said  to  occur  in  10  per  cent  of  the  cases. 

Treatment  .really  begins  with  the  beginning  of  the  attack  for  we 
believe  that. the  efficiency  of  the  nursing,  care  in  the  diet,  a  sufficiency 
of  water  ingested,  especially  care  of  the  mouth,  firmness  in  keeping 
the  patient  in  bed  during  the  convalescence,  avoidance  of  draughts 
upon  the  patient's  back,  all  tend  to  make  the  incidence  of  the  nephritis 
much  less. 

The  type  of  the  late  nephritis  is,  as  has  been  said,  an  acute  productive 
nephritis.  Its  onset  may  be  insidious  or  abrupt.  Everything  is  going 
nicely  in  convalescence  when  suddenly  an  attack  of  vomiting,  a  rise  of 
temperature  or  in  rarer  instances  a  convulsion  tell  of  the  onset;  or  the 
daily  examination  is  rewarded  by  the  first  indication  in  terms  of  albumin, 
casts  and  blood. 

With  the  more  insidious  attacks  a  dropsy  develops;  in  the  more  ful- 
minating cases  uremic  manifestations.  The  urine  is  diminished. 
Fortunately  the  vast  majority  of  those  attacked  recover,  the  urine  be- 
comes normal  in  amount  in  about  ten  days  and  becomes  free  from  blood 
and  albumin  in  two  to  six  weeks. 

Studies  of  the  renal  function,  by  the  phthalein  test,  determination 
of  urea  nitrogen  or  non-protein  nitrogen  and  creatinin.  in  the  blood  and 
observation  of  blood  pressure  will  give  one  some  idea  of  the  seriousness 
of  the  lesion.  Normal  phthaleins  run  from  60-80;  urea  nitrogen  less 
than  20  mg. ;  non-protein  nitrogen  less  then  35  mg.  and  creatinin  2  mg. 
or  less  in  each  100  c.c.  of  blood.  In  uncomplicated  cases  of  scarlet 
fever  Veeder  and  Johnston  found  that  the  systolic  pressure  in  young 
children  averaged  about  90  mm.,  in  older,  110  mm. 

When  the  kidney  function  is  impaired,  the  phthalein  figures  fall,  the 
nitrogen  increases  and  in  very  severe  cases  the  creatinin  increases  and 
the  blood  pressure  is  likely  to  go  up. 

In  all  cases  of  acute  nephritis  early  or  late  certain  definite  lines  of 
action  are  to  be  pursued. 

1.  Rest  the  kidney,  by  utilizing  other  organs  to  perform  its 
functions  vicariously  in  some  measure  and  add  as  little  as  pos- 
sible to  its  burden  by  the  proper  arrangement  of  dietary. 

2.  To  treat  the  symptoms  that  cause  distress  or  danger. 

3.  To  support  the  strength  of  the  patient  during  the  attack. 
To  consider  the  last  first,  this  object  is  attained  by  a  more  rigid  def- 
inition of  rest,  if  the  rules  have  been  relaxed  in  beginning  convalescence; 


416  TREATMENT  OF  ACUTE  INFECTIOUS  DISEASES 

by  using  blankets  on  the  bed  and  a  flannel  night-gown,  if  one  is  not  al- 
ready in  use  and  by  giving  the  warm  sponge  bath  between  the  blankets 
with  a  renewal  of  the  precautions  taken  earlier  in  the  illness. 

Diet.  If  the  onset  is  explosive  with,, nausea,  vomiting  and  fever 
and  with  anorexia,  no  food  should  be  offered  until  the  gastric  symptoms 
subside.  During  this  tune  cracked  ice  may  be  given  to  jnitigate  the 
nausea  and  vomiting  and  furnish  some  water  to  the  tissues.  If  there  is 
suppression  or  marked  oliguria,  only  water  with  sugar  and  fruit  juices, 
the  sugar  affording  some  food  value,  should  be  given  and  it  should  be 
remembered  that  if  the  kidney  has  lost  its  function  for  eliminating  water 
and  is  even  shunting  it  into  the  tissues  to  the  production  of  anasarca,  the 
ingestion  of  large  quantities  of  water  will  only  add  to  their  burden.  The 
amount  of  water  should  be  increased  as  the  increased  water  output 
betokens  a  restoration  of  function. 

We  may  then  begin  to  give  milk  in  increasing  quantities.  Our  prob- 
lem from  this  stage  on  is  to  approximate  in  the  diet  the  caloric  needs  of 
the  body  by  a  food  that  shall  offer  the  least  amount  of  work  for  the 
kidneys. 

We  may  give  milk,  with  some  cream  if  well  borne,  rice,  arrowroot, 
cornmeal  or  oatmeal  gruels,  bread  or  zwieback  and  butter  and  sugar. 

Van  Noorden  has  suggested  as  a  suitable  diet  in  an  adult  1,500  grams 
of  milk  (1  1/2  quarts),  375  grams  of  cream  (12  oz.),  50  grams  of  rice, 
50  grams  of  butter,  20  grams  of  sugar,  which  has  a  heat  value  of  2,900 
calories,  as  much  as  that  in  over  4  quarts  of  milk.  In  a  child  of  twelve 
the  demands  are  less,  some  1,600  calories,  and  the  cream  should  be  used 
much  more  sparingly. 

The  kidney  eliminates  water,  salts  and  nitrogen.  Such  a  dietary 
is  economical  in  all  these  substances,  considering  its  high  caloric  value. 

If  there  is  cedema,  all  the  articles  taken  should  be  salt  free,  salt  free 
bread  and  butter  and  no  salt  added  to  the  gruels.  Milk  contains  one 
and  one-half  grams  of  salt  to  the  liter  and  enough  for  the  metabolic 
needs. 

If  the  oedema  continues  still,  cut  down  on  the  quantity  of  fluid.  I 
have  seen  an  cedema  kept  up  simply  because  the  intake  of  water  was 
forced  beyond  the  powers  of  elimination  of  a  kidney  in  the  process  of 
resolution. 

Drinks.  Water  in  large  quantities  is  often  advised  as  a  sort  of 
a  panacea.  When  cedema  is  present  it  should  be  much  limited.  The 
blood  will  recover  water  from  the  cedematous  tissues  to  meet  its  needs. 
When  the  kidney  begins  to  eliminate  freely,  a  freer  intake  of  water  will 
be  followed  by  a  diuresis  and  in  uraemia  without  cedema  this  may  be  a 
desirable  means  of  effecting  it.  There  is  rarely  danger  in  giving  water 


SCARLET  FEVER 

enough  to  meet  the  demands  of  the  patient's  thirst.  Plain  or  aerated 
water,  mineral  waters,  lemonade,  orangeade  or  imperial  drink  may 
be  used. 

As  convalescence  is  established  other  cereals,  vegetables,  and  lastly 
fish  and  meat  may  be  added. 

Rest  to  the  kidney  is  afforded,  as  shown  by  the  choice  of  the 
dietary  and  is  further  accorded  by  the  assistance  lent  in  elimination  by 
the  other  emunctories. 

Purgation.  One  of  these  emunctories  is  the  intestine.  The 
movements  should  be  rendered  watery  and  fairly  copious  by  the  use 
of  salts,  such  as  Rochelle  salt,  Epsom  salt  or  sodium  phosphate,  in 
doses  of  gss.  to  i  (15-30  Gm.)  in  adult  and  half  the  dose  to  the  child. 
Compound  jalap  powder  is  also  of  use,  especially  in  the  adult  in  doses 
of  3i  (4  Gm.).  It  must  be  remembered  that  purgation  may  be  carried 
to  the  point  of  exhaustion  and  do  more  harm  than  good. 

Diaphoresis.     The  second  great  emunctory  is  the  skin. 

To  effect  copious  sweating  perhaps  the  best  measure  is  the  hot  pack. 
It  can  be  given  once  or  twice  a  day,  depending  on  the  urgency  of  the 
attacks.  The  technique  follows: 

"  Hot  Packs.  To  give  the  hot  pack:  Cover  the  patient  with  a 
blanket,  folding  down  the  upper  bed-clothes  to  the  foot  of  the  bed.  Slip 
two  blankets  with  a  rubber  between  them  under  him.  These  must 
extend  from  the  head  to  the  feet.  Put  an  ice-cap  or  an  ice-compress  on 
his  head,  changing  the  latter  every  two  minutes.  Line  a  foot  tub  with  a 
large  rubber  sheet — rubber  side  upward.  Put  in  the  tub  hot-water  bags 
— four,  if  possible.  Soak  two  small  blankets — one  of  which  is  kept 
doubled — in  water  150°  F.,  leaving  out  two  ends  to  hold  while  twisting. 
Wring  the  blankets  quite  dry,  put  them  in  the  tub  with  the  hot-water 
bags,  and  cover  with  the  ends  of  the  rubber  sheet  in  order  that  they 
may  be  kept  hot  while  being  taken  to  the  bedside.  Slip  the  doubled 
blanket  under  the  patient.  Stretch  the  other  blanket  over  his  chest  and 
around  his  arms  and  legs,  without  exposing  him,  and  tuck  it  snugly  around 
him,  especially  at  the  neck.  Place  one  of  the  hot-water  bags  at  his  feet, 
one  under  his  knees  and  one  in  each  axilla  and  cover  all  with  the  rubber 
which  has  been  lining  the  tub.  Draw  up  the  ends  of  the  under  blankets 
and  rubber  tightly  around  the  patient,  tuck  them  in  and  pull  up  the 
bed-clothes.  Take  the  pulse  frequently  at  the  temporal  artery.  En- 
courage the  patient  to  drink  copiously — hot  drinks,  seltzer  or  vichy. 
After  20  or  30  minutes  remove  the  wet  blankets  and  rubbers,  and  roll  the 
dry  blankets  tightly  around  the  patient.  Let  him  remain  thus  for  an 
hour,  keeping  the  ice-bag  at  his  head  and  hot-water  bag  at  his  feet.  At 
the  end  of  the  hour  give  him  an  alcohol  rub  and  remove  the  blanket. 


418  TREATMENT  OF  ACUTE  INFECTIOUS  DISEASES 

Rubbing  the  body  with  alcohol  under  such  circumstances,  energises  the 
nerve  centres  and  transforms  the  passive  activity  of  the  skin  into  active 
vascular  excitability."  Practical  Nursing,  Maxwell-Pope,  p.  122. 

"  Modified  Hot  Packs.  Modified  hot  packs  are  sometimes  given 
in  connection  with  diaphoretic  drugs,  to  further  their  action.  To  apply 
such  a  pack,  remove  the  patient's  night  gown,  roll, him  in  a  hot  dry 
blanket  place  hot-water  bags  at  his  feet  and  along  his  sides,  and  cover 
him  with  a  rubber  sheet  tucking  it  firmly  under  the  mattress.  Leave  him 
thus  for  half  an  hour,  an  hour  or  longer  if  necessary."  Ibid.,  p.  123. 

The  difficulty  in  a  household  of  achieving  the  technique  of  a  hot 
pack  often  results  in  the  patient's  being  rolled  in  a  blanket  cold  by  the 
time  it  is  accomplished.  I  have  found  the  following  modification  ex- 
cellent : 

A  blanket  folded  to  a  little  more  than  the  width  of  the  patient's  body 
is  wrung  out  as  described,  quickly  laid  on  the  rubber  sheet  and  the 
patient,  rolled  in  a  dry  blanket,  laid  upon  it.  Over  the  patient  are  placed 
more  blankets  and  sometimes  an  impermeable  rubber  sheet  over  these. 
The  whole  procedure  lasts  about  an  hour.  During  the  pack  water  is 
given  and  ice  kept  at  the  head. 

Another  procedure  is  the  hot-air  bath,  to  which  some  patients  respond 
better  than  to  the  pack. 

"  To  give  a  hot-air  bath  in  bed,  the  following  articles  will  be  needed: 

An  ice  cap. 

A  hot  water-bag  and  cover. 

Three  blankets. 

Two  large  rubber  blankets. 

Bed  cradles,  the  number  depending  on  their  size. 

A  bath-thermometer. 

A  hot-air  pipe  and  support. 

Asbestos  to  put  around  the  top  of  the  pipe. 

A  Bunsen  burner  or  alcohol  lamp. 

Hot  drinks. 

For  a  vapor  bath  a  croup  kettle  will  be  needed  instead  of  the  hot-air 
pipe,  and  a  gas  or  large  alcohol  stove  will  be  better  than  a  Bunsen  burner. 

In  a  private  house  the  elbow  of  a  stove  pipe,  five  or  six  inches  in 
diameter,  can  be  substituted  for  the  hot-air  pipe,  and  an  old  screen, 
clothes-horse  or  wooden  chairs  for  the  bed  cradle. 

Method  of  Giving  Bath.  Cover  the  patient  with  a  blanket. 
Fold  down  and  remove  the  top  bed  clothes.  Put  a  sufficient  number  of 
bed  cradles  over  him  to  extend  from  his  neck  to  his  feet  and  cover  these 
with  rubber.  Draw  out  the  blanket  covering  him  and  pass  it  up  over  the 
cradle  under  the  rubber.  Take  off  his  nightgown,  put  the  ice-cap  on 


SCARLET  FEVER  419 

his  head  and  the  hot-water  bag,  covered,  at  his  feet,  wrapping  the  latter 
in  a  portion  of  the  blanket  on  which  he  is  lying.  Hang  the  atmospheric 
thermometer  on  the  cradle  at  the  top.  Draw  the  ends  of  the  rubber  and 
blanket,  which  are  under  the  patient,  up  over  the  cradle,  under  the  rubber 
and  blankets  covering  it.  Tuck  in  the  latter  under  the  patient  on  both 
sides  and  around  the  shoulders  and  neck.  At  the  bottom,  tuck  them  in 
under  the  mattress  folding  them  around  the  air  pipe.  Put  the  top  end 
of  the  air  pipe  in  under  the  cradle  three  or.  four  inches  and  cover  this  part 
of  the  pipe  and  as  much  more  of  it  as  the  clothes  are  likely  to  touch,  with 
asbestos  or  cold  blanket  dampened.  Tie  the  pipe  to  the  cradle  at  least 
four  inches  above  the  feet.  See  to  it  that  the  feet  and  lower  part  of  the 
legs  are  securely  covered  and  apart.  Put  the  bed  clothes  over  the  cradle. 
Tuck  them  in  only  at  the  foot  and  treat  them  there  in  the  same  manner 
as  the  blanket,  taking  care  that  the  asbestos  protects  them  from  the  hot 
pipe.  Put  the  lamp  or  burner  in  the  pipe  and  light  it,  so  regulating  it 
that  the  temperature  inside  the  cradle  will  be  raised  from  150-175°  F. 
Give  the  patient  hot  drinks  of  Vichy  while  he  is  in  the  bath  and  watch 
his  pulse  carefully.  The  bath  is  generally  continued  twenty  minutes 
after  the  stated  temperature  is  reached.  The  after  treatment  is  the  same 
as  for  the  pack."  Practical  Nursing,  Maxwell-Pope,  p.  124. 

Where  there  is  electricity  the  most  convenient  sort  of  heat  is  from 
electric  light  bulbs  suspended  from  the  top  of  the  cradle.  Three  100  watt 
120  Volt  bulbs  hung  12  to  14  inches  apart  will  suffice  to  give  the  desired 
temperature.  Care  must  be  used  to  avoid  the  patient  or  the  bedding 
coming  in  contact  with  these  bulbs.  The  common  wire  cage  used  to 
protect  electric  light  bulbs  will  serve  well. 

Another  procedure  is  the  hot  bath,  beginning  at  95°  F.  and  slowly 
increasing  the  heat  to  100°  F.  This  is  kept  up  for  ten  or  fifteen  minutes, 
then  the  patient  wrapped  in  a  dry  or  hot  moist  blanket  or  pack  and  con- 
tinued for  another  half  hour. 

It  has  been  again  and  again  noted  by  clinicians  that  the  hot  pack 
in  the  cedematous  has  seemed  to  precipitate  an  attack  of  uraemia.  Close 
observation  must  be  kept  upon  the  patient  for  any  evidence  of  the  same, 
headaches,  twitchings,  nausea  and  vomiting  or  hypertension. 

Drugs.  Pilocarpine  has  been  used  and  will  usually  induce  a 
marked  diaphoresis.  It  is,  however,  fraught  with  dangers,  the  most 
imminent  of  which  is  oedema  of  the  lungs,  and  may  well  be  dispensed 
with. 

Treatment  of  symptoms  that  cause  distress  or  danger. 

Congestion  of  the  kidneys  as  evidenced  by  diminished  urine  or  at 
times  by  lumbar  pain. 

Cupping.     Two  or  more  cups  may  be  placed  over  the  kidney 


420  TREATMENT  OF  ACUTE  INFECTIOUS  DISEASES 

region  on  either  side  and  left  on  for  15  to  20  minutes  or  until  the  capil- 
laries are  well  dilated.  (For  technique  of  cupping,  see  Pneumonia, 
Chap.  IX.) 

Wet  cupping  or  the  application  of  leeches  is  advised  by  some  author- 
ities. I  am  not  convinced  that  the  letting  of  blood  here  relieves  conges- 
tion in  the  kidneys  better  than  venesection  elsewhere.  .So  far  as  the 
withdrawal  of  blood  relieves  the  circulation  in  the  presence  of  hyper- 
tension or  uraemia,  these  measures  do  good.  (For  the  technique  of  wet 
cuppijig  and  leeching,  see  Pneumonia,  Chap.  IX.) 

Such  good  as  these  measures  do,  I  believe  is  to  be  referred  to  reflex 
processes,  starting  in  the  skin  area  operated  on  and  impinging  on  the 
deep  vessels. 

Counterirritation.  For  this  purpose  hot  poultices,  mustard  paste 
or  hot  fomentations  may  be  used.  (For  the  technique  of  applying 
poultices,  fomentations,  mustard  paste,  see  Pneumonia,  Chap.  IX.) 

Diuretics.  When  the  acutest  stages  have  passed,  we  may  ven- 
ture to  encourage  diuresis  by  the  mildest  of  diuretics,  milk  and  water, 
and  the  drinks  mentioned.  These  may  be  followed  by  the  alkaline  salts, 
potassium  citrate,  potassium  acetate  or  bicarbonate  of  potash  or  so- 
dium in  doses  of  gr.  xx  to  xxx  (1.30-2  Gm.)  every  two  or  three  hours,  or 
the  dose  for  children  according  to  age  until  the  urine  reacts  alkaline,  then 
reduce  until  an  amount  is  continued  just  enough  to  keep  the  urine  alka- 
line. These  alkaline  salts  are  often  mixed  in  equal  parts. 

The  use  of  diuretics  of  the  purin  series,  theobromine,  caffeine,  etc.,  in 
acute  nephritis  I  advise  against.  They  have  been  shown  to  be  dis- 
tinctly irritating  to  the  epithelium  of  the  kidney.  If  used  at  all  in  the 
subacute  stages  it  should  be  with  caution;  then  one  may  use  the  double 
salt  of  sodium  salicylate  and  theobromine  or  diuretin  in  doses  of  gr.  v  to 
gr.  x  (0.30-0.60  Gm.),  according  to  age,  three  times  a  day  for  2  days  only, 
or  the  double  salt  of  sodium  acetate  and  theobromine,  in  the  same  doses, 
or  theocine  gr.  v  (0.33  Gm.)  three  times  a  day  for  one  day  only. 

If  the  heart  is  weak  caffeine  in  the  form  of  the  soluble  double  salts  of 
sodium  benzoate  or  sodium  salicylate  gr.  iii  to  v  (0.20-0.30  Gm.)  three 
or  four  times  a  day  or  gr.  i  to  gr.  ii  (0.060-0.120  Gm.)  in  a  child  of  five 
years  has  been  advised.  The  same  objection  to  its  use  obtains,  however, 
as  in  the  case  of  diuretin  and  theocine.  Caffeine  has  a  selective  action 
on  the  renal  vessels  causing  dilatation,  facilitating  blood  supply  and 
diuresis.  If  the  heart,  however,  is  a  factor  in  the  condition,  increasing 
congestion  of  the  kidney,  by  its  own  decompensation,  digitalis  is  em- 
phatically indicated  and  is  to  be  used  as  described  under  the  cardio- 
vascular apparatus. 

(Edema  is  as  a  rule  not  massive  and  is  relieved  by  the  measures 


SCARLET  FEVER  421 

already  mentioned.  It  is  possible,  however,  for  fluid  to  accumulate  in 
the  subcutaneous  tissues  and  in  the  serous  sacks  to  a  degree  demanding 
immediate  interference. 

If  the  anasarca  is  marked  or  obstinate,  the  tissues  should  be  drained 
By  far  the  neatest  method  is  by  the  Southey  tubes.  I  have  seen  the  most 
gratifying  results  follow  this  procedure  in  a  young  child  when  all  other 
measures  failed. 

Southey  tubes  are  small  silver  or  silver-plated  trocars  and  cannulas, 
about  1-1  1/2  inches  long  of  small  calibre,  usually  four  in  a  set.  They  are 
introduced  one  behind  each  internal  and  external  malleolus,  at  such  an 
angle  as  to  drain  well.  The  trochar  is  withdrawn  and  the  cannula  se- 
cured by  a  bit  of  silk  tied  about  a  groove  near  the  end  for  that  purpose 
and  secured  with  adhesive  plaster.  No  blood  should  be  drawn;  crystal 
clear  water  flows  freely,  and  the  quantity  in  24  hours  is  often  amazing, 
amounting  to  quarts.  Tissues  so  infiltrated  scarcely  feel  the  introduction 
of  the  tube. 

When  Southey  tubes  are  not  obtainable,  multiple  punctures,  6-12  on 
the  dependent  part  of  each  leg  with  a  bistoury  protected  1/8"  to  1/4" 
from  the  point  with  adhesive  plaster  may  be  made  or  the  parts  may  be 
cross-hatched  with  a  scalpel.  The  methods  are  cruder  and  it  is  less 
easy  to  prevent  infection.  None  should  draw  blood. 

If  the  legs  hang  down  or  are  bent  at  the  knee  when  the  patient  is 
recumbent  drainage  is  facilitated.  Whatever  the  method  used,  strict 
asepsis  must  be  observed  in  the  procedure  and  the  legs  dressed  with  loose 
gauze  handkerchiefs  or  fluff.  With  any  signs  of  irritation  about  the 
puncture  withdraw  the  tubes. 

If  the  hydrothorax  is  sufficient  to  embarrass  either  the  circulation 
or  respiration,  it  should  be  removed  by  a  paracentesis. 

The  same  procedure  must  be  undertaken  for  ascites,  if  the  fluid  in 
the  peritoneal  cavity  embarrasses  respiration  or  cardiac  action. 

Uraemia.  With  the  first  premonition  of  ursemia  one  should  have 
recourse  to  vigorous  purgation  and  diaphoresis.  With  hypertension, 
twitching  foretelling  convulsions,  venesection  is  indicated,  the  amount 
depending  on  the  age  and  size,  10  to  16  ounces  in  the  adult,  3  to  6  in  a 
child  of  five  years.  This  may  be  followed  by  a  saline  infusion  of  twice 
the  amount  taken;  but  is  not  imperative  in  the  stronger  patients. 

The  muscular  twitching  demands  sedatives,  chloral,  given  by  the 
rectum  in  a  couple  of  ounces  of  warm  milk,  gr.  xxx  to  3i  (2-4  Gm.)  in 
the  adult,  gr.  v  to  gr.  x  (0.30-0.60  Gm.)  in  the  child  of  five  to  six  years. 

This  can  be  repeated  in  a  couple  of  hours  if  needed. 

The  hot  pack  often  affords  relief,  but  the  patient's  condition,  pulse, 
respiration,  color  and  his  general  response  should  be  studied.  The 


422  TREATMENT  OF  ACUTE  INFECTIOUS  DISEASES 

length  of  the  time,  1/4  to  one  hour,  and  number;  one,  two  or  three  a 
day,  depends  on  the  patient's  response  to  the  procedure.  (Technique, 
see  above.) 

Convulsions.  The  one  drug  efficacious  at  the  moment  is  chlor- 
oform, continued  until  the  attack  ceases.  This  is  followed  at  once  by  a 
hypodermic  of  morphine  sulphate  to  prevent  recurrence^  in  the  adult 
gr.  1/4  (0.015  Gm.)  and  repeat  in  a  half  hour  if  needed;  in  the  child  gr. 
1/24  (0.0025  Gm.)  and  in  an  hour  gr.  1/48  (0.0015  Gm.)  if  needed. 

An  enteroclysis  of  normal  salt  solution,  two  quarts  at  a  time  and 
several  times  a  day,  given  at  104°  F.  to  108°  F.  acts  often  as  a  vigorous 
diuretic  and  assists  in  elimination  of  the  toxic  agent. 

With  hypertension,  amelioration  of  the  condition  may  follow  upon 
the  administration  of  nitroglycerin,  gr.  1/100  to  gr.  1/50  (0.0006-0.0015 
Gm.)  every  two  hours  in  the  adult  or  gr.  1/200  (0.0003  Gm.)  every  hour 
for  five  or  six  doses  at  five  years. 

Headache  is  best  relieved  by  an  ice  bag  to  the  head  or  the 
nape  of  the  neck.  Small  doses  of  the  milder  coal-tars  may  be  used 
cautiously,  acetphenetidin  (phenacetin)  gr.  i  to  gr.  iss.  (0.060-0.10  Gm.) 
every  hour  for  three  or  four  doses  in  the  child;  gr.  v  (0.30  Gm.)  at  a  dose 
in  the  adult.  Codeine  phosphate  gr.  1/4  (0.015  Gm.)  hypodermically 
for  an  adult  or  according  to  age  for  children  is  useful. 

Lumbar  Puncture.  Recurring  convulsions  or  excruciating  head- 
ache may  find  relief  in  a  lumbar  puncture,  a  comparatively  simple 
procedure  in  the  child.  (For  technique,  see  Cerebro-Spinal  Meningitis, 
Chap.  XXV.) 

Nausea  and  Vomiting.  This  is  an  expression  of  uraemia  and 
will  improve  with  the  elimination  of  the  causative  agent.  For  immediate 
help,  we  stop  all  effort  at  food  administration,  give  cracked  ice,  apply 
£  mustard  paste  to  epigastrium  of  one  part  of  mustard  to  four,  five  or  six 
of  flour,  depending  on  the  sensitiveness  of  the  skin,  mixed  with  cold  or 
tepid  water  and  leave  until  the  part  is  reddened,  or  give  internally 
bismuth  subnitrate,  gr.  x  to  gr.  xv  (0.60-1  Gm.),  bicarbonate  of  soda 
gr.  v  to  gr.  x  (0.30-0.60  Grin.),  or  oxalate  of  cerium,  gr.  ii  to  gr.  v  (0.15- 
0.30  Gm.),  or  they  may  be  combined,  as 

Bismuth  Subnitratis 15.        5ss. 

Sodii  Bicarbonatis 10.        gr.  cl 

i  Cerii  Oxalatis 5 .        gr.  Ixxv 

M.  et  div.  in  chart,  no.  xv. 

S.    One  every  two  hours  in  a  little  water  or  food. 

Rare  complications  in  the  course  of  the  nephritis,  such  as  pneu- 
monia, pleurisy,  endo-  or  peri-carditis  must  be  treated  as  if  primary. 
(Edema  of  lungs  occurs  as  a  cause  of  death  in  nephritis. 


SCARLET  FEVER  423 

Anaemia  is  a  striking  feature  of  a  nephritis.  In  convalescence 
iron  is  indicated.  It  may  be  given  as  Blaud's  pill  or  Vallet's  mass  in 
doses  of  gr.  iii  to  gr.  v  (0.20-0.30  Gm.)  three  times  a  day  or  as  Basham's 
mixture,  Liquor  Ferri  et  Ammonii  Acetatis,  which  contains  4  per  cent, 
tincture  of  ferric  chloride,  converted  into  acetate.  Dose  3i  to  iv  (4-8  c.c.) 
three  times  a  day. 

Convalescence.  After  an  acute  attack  great  care  must  be  taken 
to  prevent  a  recurrence  by  too  early  exposure.  The  patient  should 
remain  in  bed  until  albuminuria  ceases  or  for  four  or  five  weeks.  If  the 
albumin  persists  after  that,  one  must  consider  the  depressing  effect  of  too 
long  confinement  to  bed  and  the  patient  be  allowed  to  sit  up  tentatively, 
the  albumin,  casts,  total  quantity  and  specific  gravity  being  carefully 
noted  with  each  increase  of  license.  If  the  condition  is  not  aggravated, 
the  patient  may  be  allowed  about  the  house  or  out  of  doors  in  suitable, 
weather;  but  with  the  slightest  indication  of  recurrence  should  be  put  to 
bed  again.  If  the  evidences  of  nephritis  continue  and  the  patient  is  able 
to  take  advantage  of  a  change  of  climate  he  may  be  removed  to  such  a 
place  as  allows  much  out  of  doors  life. 

Woolen  underclothing  must  be  worn  and  outer  clothing  care- 
fully adapted  to  the  weather.  Warnings  against  remaining  in  wet  clothes 
and  undue  exposure  to  the  weather  must  be  reiterated.  On  the  occasion 
of  any  acute  infection  the  kidneys  should  be  watched  with  especial  care. 
From  time  to  time,  for  years  after,  the  urine  should  be  examined  at 
intervals  of  3  to  6  months  to  appreciate  the  insidious  advance  of  a 
chronic  process. 

The  sum  total  of  prophylaxis  is  after  all  the  observance  of  the  laws 
of  hygiene,  clean  bodies,  fresh  air,  good  food  and  right  living. 

The  Heart.  Mention  has  been  made  of  the  heart  in  consider- 
ing the  cardio-vascular  apparatus  and  its  part  in  nephritis  has  been 
touched  upon ;  but  in  addition  to  these  there  may  rarely  be  an  endocar- 
ditis (in  something  less  than  1/2  per  cent.)  and  still  more  rarely  a  peri- 
carditis; the  cardiac  complications  are  most  common  in  septic  cases,  and 
with  post-scarlatinal  nephritis  and  streptococcus  pneumonia. 

Myocardial  changes  occur  as  well.  All  this  may  be  found  with  or 
without  articular  involvement.  Acute  dilatation  may  be  the  cause  of 
death.  (Holt.)  More  rarely  there  may  be  a  toxic  arteriosclerosis  or 
even  an  aortitis. 

The  treatment  of  these  conditions  are  the  same  as  under  other  circum- 
stances, rest,  the  ice  bag,  and  if  the  myocardium  becomes  involved  and 
shows  signs  of  weakening,  digitalis.  .(See  Acute  Rheumatic  Fever, 
Chap.  III.) 

Broncho-Pneumonia  is  likely  to  follow  upon  septic  cases,  but 


424  TREATMENT  OF  ACUTE  INFECTIOUS  DISEASES 


may  more  rarely  happen  during  desquamation.    It  is  a  far  less  serious 
complication  than  in  measles  or  whooping  cough. 
The  treatment  is  as  elsewhere.    (See  Pneumonia,  Chap.  IX.) 
Pleurisy  occurs  not  infrequently  and  occasionally,  early  or  late,  an 
empyema,   always  a  grave  condition,   demanding  prompt   operative 
interference.    (See  Pneumonia,  Chap.  IX.) 

Still  more  rarely  one  meets  noma.  It  is  to  be  combated  by  curetting 
and  the  application  of  fuming  nitric  acid  and  if  this  fails  to  stop  its 
extension,  excision  must  be  done.  McGuire  advises  application  of  thick 
paste  of  bismuth  subnitrate  and  water.  Chorea,  peritonitis,  symmetrical 
gangrene  and  other  very  rare  happenings  are  to  be  met  as  under  other 
conditions. 

Relapses.  Relapses  may  occur,  as  often,  it  is  said  by  some  au- 
thorities, as  1  per  cent.  It  is  most  usual  in  the  fourth  or  fifth  week, 
but  may  be  delayed  until  the  sixth  or  seventh.  It  is  in  all  particulars  like 
the  original  attack  and  is  to  be  treated  in  the  same  manner. 

Recurrences  are  possible,  usually  many  years  later,  but  are  very 
rare. 

Discharge  of  Patient.  The  patient  should  not  be  released  from 
isolation  until  desquamation  is  completed  and  all  discharges  from  the 
mucous  membranes  or  suppurating  tissues,  organs  or  structures 
cease. 

Even  in  the  mildest  cases,  however  soon  the  desquamation  may 
seem  complete,  the  patient  should  be  isolated  at  least  four  weeks  and 
six  weeks  is  safer.  In  fact  the  average  case  has  to  be  isolated  for  this 
time.  But  even  then,  if  the  desquamation  is  not  complete  (and  the  feet 
have  especially  to  be  attended  to)  isolation  must  continue.  It  is  to  be 
remembered,  as  before  mentioned,  that  harsh  measures  to  effect  des- 
quamation may  set  up  a  dermatitis  and  defeat  the  purpose.  If,  however, 
when  desquamation  is  quite  at  an  end,  there  is  a  discharging  nose,  ear  or 
gland,  the  patient  must  not  be  released  until  this  ceases. 

When  all  symptoms  have  ceased  and  the  patient  is  released  from 
quarantine,  if  a  child,  he  should  not  mingle  with  other  children  for  a 
month  to  come  nor  sleep  with  them  for  three  months.  (Holt.) 

When  the  child  is  ready  for  release  he  is  given  a  thorough  soap  and 
water  bath  and  then  one  of  phenol  (carbolic)  1  to  50  or  bichloride  1  to 
5,000.  The  scalp  and  hair  are  thoroughly  shampooed. 

No  more  excellent  guide  for  routine  procedure  can  be  taken  than 
Northrup's  description  of  that  in  use  in  some  of  the  New  York  Hospitals. 
(NothnageFs  Encyclopedia  of  Practical  Medicine,  1902,  English  Trans- 
lation, 611,  quoted  from  Weaver  in  Musser  and  Kelly's  Practical  Treat- 
ment.) "  During  the  week  preceding  discharge  patients  have  their  ears 


SCARLET  FEVER  425 

irrigated  with  bichloride  solution  1  to  8,000X  and  the  scalp  shampooed  on 
alternate  days."  When  discharged 

"(1)  The  ears  are  irrigated  with  bichloride  solution  1  to  8,000; 

(2)  the  scalp  is  shampooed  with  soap  and  water; 

(3)  the  scalp  is  shampooed  with  bichloride  1  to  2,000; 

(4)  a  tub-bath  is  given  of  soap  and  water; 

(5)  a  tub-bath  is  given  of  bichloride  solution  1  to  8,000  for  twenty 
minutes; 

(6)  a  sponge-bath  is  given  of  bichloride  solution  1  to  2,000; 

(7)  the  bichloride  is  sponged  off  with  sterile  water; 

(8)  a  nasal  spray  is  given  of  bichloride  solution  1  to  8,000; 

(9)  the  mouth  is  cleansed  with  saturated  solution  of  boric  acid." 
The  child  is  then  taken  into  a  clean  room  and  clothed  in  clean  clothes. 
Fumigation   and   Sterilization.     Washable   clothing   should   be 

disinfected  by  steam  or  by  boiling  an  hour.  Mattresses,  heavy  blankets, 
pillows  and  articles  that  cannot  be  washed  should  be  steamed  where  it 
is  possible  to  have  recourse  to  a  properly  constructed  plant. 

All  articles  that  have  little  value  should  be  burned  and  toys  certainly. 
No  child  should  ever  be  given  a  toy  once  in  the  sick  room,  no  matter 
how  sterilized. 

Metal  objects  may  be  immersed  in  strong  phenol  (carbolic  acid).  The 
room  should  be  cleaned  by  having  the  floors,  woodwork  and  the  smooth 
walls  washed  down  with  cloths  wrung  out  of  1  to  2,000  bichloride  solu- 
tion. Then  the  room  should  be  fumigated  with  sulphur  or  formaldehyde. 
These  gases  should  be  generated  in  the  presence  of  moisture  to  be  effec- 
tual. 

Sulphur  destroys  many  fabrics  and  injures  other  articles  and  is  less 
effectual  than  formaldehyde.  Where  it  is  possible  skilled  assistance 
should  be  sought  in  this  important  procedure;  where  this  may  not  be 
obtained,  the  room  is  to  be  sealed  with  strips  about  the  doors  and  win- 
dows, the  key  holes  plugged  and  formaldehyde  gas  generated  by  some  of 
the  contrivances  on  the  market.  Candles  are  made  for  this  purpose,  but 
too  implicit  faith  in  their  efficacy  must  not  be  granted.  They  should  be 
burned  in  the  presence  of  moisture,  such  as  may  be  obtained  from  a  dish 
of  water  over  an  alcohol  lamp,  and  the  room  sealed  for  some  twelve  hours. 

Such  fumigation  does  not  excuse  one  from  the  duty  of  repainting, 
repapering,  or  recalcimining  this  room. 

Fumigation.  At  the  present  moment  there  is  a  considerable 
controversy  among  the  authorities  as  to  the  necessity  of  terminal  fumi- 
gation; The  Board  of  Health  of  the  City  of  New  York,  following  the 
lead  of  Chapin  of  Providence,  R.  I.,  considers  terminal  fumigation  in  all 
1  This  in  cases  in  which  there  may  be  no  otorrhea. 


426  TREATMENT  OF  ACUTE  INFECTIOUS  DISEASES 

infectious  diseases  except  anterior  poliomyelitis,  typhus  fever  and  small 
pox  as  unnecessary,  providing  proper  isolation  of  the  patient  during 
the  disease  with  destruction  of  infectious  discharges  has  been  properly 
carried  out.  There  can  be  no  question  tiiat  if  these  precautions  are 
heeded  the  necessity  for  terminal  fumigation  is  materially  lessened. 

Beginning  in  1914  the  New  York  Board  of  Health  ceased  to  fumigate 
in  the  Boroughs  of  Manhattan  and  the  Bronx  after  all  the  minor  con- 
tagious diseases  including  scarlet  fever,  diphtheria  and  measles  while  the 
practice  was  continued  in  the  Borough  of  Brooklyn.  After  a  long  series 
of  cases  had  been  investigated  the  Health  authorities  of  New  York 
could  determine  no  particular  difference  in  the  number  of  late  cases 
reported  from  controls.  This  was  in  agreement  with  the  observations  of 
Chapin  in  Providence.  Moreover,  it  is  well  known  that  most  of  the 
pathogenic  organisms  have  but  slight  viability  after  separation  from  the 
host  and  after  exposure  for  an  appreciable  time  to  drying  and  sunlight. 

In  place,  then,  of  putting  reliance  upon  fumigation  at  the  end  of  the 
clinical  course  of  the  disease  emphasis  is  laid  on  the  attention  to  the 
discharges  during  the  course  of  the  disease  and  thorough  cleansing  with 
soap  and  water  or  boiling  of  the  articles  that  have  been  soiled  by  dis- 
charges from  the  patient. 

On  the  other  hand  at  the  date  of  this  writing  the  Health  Department 
of  the  District  of  Columbia  still  continues  to  disinfect  premises  after 
diphtheria,  scarlet  fever  and  the  major  contagious  diseases. 

In  a  treatise  of  this  kind  the  author  feels  that  he  can  only  put  the 
pros  and  cons  before  the  reader  and  would  advise  that  in  those  environ- 
ments where  the  rules  and  regulations  laid  down  for  the  isolation  of 
patients  and  destruction  of  discharges  cannot  be  carried  out  or  are 
wilfully  neglected  terminal  fumigation  be  carried  out,  but  would  em- 
phasize the  inefficiency  of  most  of  these  terminal  fumigations  and  the 
great  danger  of  considering  them  as  excuses  for  neglect  of  instructions 
heretofore  cited. 

Prophylaxis.  This  subject  has  already  been  covered  in  part  as 
regards  disposition  of  contacts,  discharge  of  patient  and  fumigation.  It 
includes,  furthermore,  school  inspection  of  children  daily  with  prompt 
attention  to  early  signs  of  infection,  following  up  absentees  from  school 
to  determine  sickness  and  its  nature,  supervision  of  milk  supply,  enforce- 
ment of  law  against  spitting  in  public  places  and  public  lectures  on  modes 
of  conveyance  of  disease. 


SCARLET  FEVER  427 

SUMMARY 
Incubation. 

Two  to  four  days.    Ten  to  twelve  days. 

Period  of  isolation  of  those  exposed  should  be  eight  days.    An  excess 
of  precaution  would  set  it  at  three  weeks. 

Onset  and  diagnosis. 
Vomiting,  fever,  sore  throat. 

Erythematous  eruption  (twelve  to  twenty-four  hours  after  onset). 
Throat  shows  bright  injection. 

Tongue  shows  hypertrophied  papillae  at  tip  and  edges. 
Leucocytosis  and  polynucleosis. 
Later. 

Desquamation. 

Eosinophilia. 

Nephritis. 

Distribution  of  the  family. 

Adults.    Those  who  have  not  had  Scarlet  Fever  should  come  in  con- 
tact with  the  patient  as  little  as  is  compatible  with  their  duty.    All 
adults  should  avoid  contact  with  children  outside.     If  contact 
with  children  outside  is  imperative,  adults  should  remove  from 
the  environment  of  infection  during  its  course. 
Teachers  in  the  family  should  move  from  contact  with  patient  and 
notify  health  authorities  and  resume  working  only  with  their 
consent. 
No  member  in  contact  with  case  should  handle  food  supply  for 

eight  days. 

Other  children  of  the  family. 
Removed  to  another  house,  until  end  of  illness. 
Kept  from  contact  with  other  children  for  eight  days.    Excess  of 

precaution  sets  it  at  three  weeks. 

Should  not  go  to  school  for  three  weeks  from  beginning  of  isola- 
tion. Should  not  go  to  school  at  all  during  patient's  illness,  if 
there  is  any  communication  between  them  and  members  of  the 
family  in  contact  with  the  patient  or  from  the  home  of  the 
patient. 
If  it  is  not  possible  to  remove  the  children  to  another  house,  avoid 

direct  or  indirect  contact  with  patient. 

All  contacts  should  have  throats  and  skin  inspected  and  temperature 
taken  two  to  three  times  a  day  for  a  week  to  determine  early 
signs  and  symptoms  of  disease.  Physician  should  attend  to  them 
before  seeing  patient. 

Room. 

Sumcient  air  space.    Good  ventilation.    Light.    Top  floor  excellent. 

Nearness  to  a  bath-room  desirable. 

Affording  ingress  and  exit  without  passing  through  family  apart- 
ments desirable.  Approach  through  balcony  or  verandah  for 
example. 


428  TREATMENT  OF  ACUTE  INFECTIOUS  DISEASES 

Open  fire  place  a  convenience. 

Strip  room  of  furniture,  carpet,  adornments. 
Floor  bare  or  covered  with  carpet  lining  and  over  this  unbleached 

muslin. 

Sealing  doors,  except  those  in  use. 
Entrance  to  all  rooms  protected  by  sheets. 
One  sheet  on  outside  of  doorway  attached  to  top  and  right  side. 

One  sheet  inside  of  doorway  attached  to  top  and  left  side  or  vice- 
versa. 
Floor  and  woodwork. 

Rubbed  from  time  to  time  with  1-1,000  bichloride  of  mercury 

(burn  the  cloths  used). 
If  the  floor  is  covered  sprinkle  with  same  solution. 

The  nurse. 

One  for  day  and  one  for  night  or  one  with  a  member  of  the  family. 

If  member  of  family  must  be  nurse,  she  must  be  isolated  from  the 

rest  of  the  family.    She  should  wear  gown  and  cap. 
Handling  secretions  she  should  wear  rubber  gloves. 
She  should  use  an  occasional  throat  spray  of  a  mild  antiseptic,  2-4 

per  cent,  boric  acid  solution,  or  half  strength  Dobell's  solution. 

Must  not  come  in  contact  with  other  members  of  the  family  or 

susceptible  people  outside.    Should  not  sleep  or  eat  in  the  sick  room. 
Should  have  own  room  adjacent. 
Should  take  air  and  exercise.    Should  change  clothes  in  going  out 

and  if  coming  in  contact  with  others  should  wash  hair. 

The  physician. 

Leave  overcoat  and  coat  and  vest  in  bath-room. 

Don  gown,  long  and  tight  at  wrists  rubber  gloves.  Failing  this  a  sheet. 

Failing  this  wear  overcoat  and  street  gloves,  cap. 
Wear  rubbers,  and  turn  up  trousers. 

Leave  all  instruments  in  sick  room  or  bath-room  (including  stetho- 
scope). Disinfect  before  using  again. 

Visit  as  short  as  compatible  with  proper  examinations. 

On  leaving.    Wash  face  and  hands  with  soap  and  water. 
Follow  with  alcohol  or  bichloride  of  mercury  1-1,000  or  phenol 
or  lysol  1  per  cent. 

A  careful  physician  will  change  his  clothes  and  take  a  bath  before 
seeing  other  children.  At  least  plan  to  see  Scarlet  Fever  cases 
either  early  or  late  in  the  day.  Spend  some  time  later  in  the  open 
air,  and  do  not  visit  a  child  immediately. 

Do  not  take  an  obstetric  case. 

Precautions  in  the  sick  room. 

Thermometer.    Leave  the  thermometer  in  the  sick  room  always. 

Keep  it  in  2  per  cent,  to  5  per  cent,  phenol  solution. 
Tongue  depressors.    Should  be  of  wood  or  glass;  better  wooden  ones. 

Keep  glass  in  phenol  solution  2  to  5  per  cent. 


SCARLET  FEVER  429 

Syringe  nozzles.    Glass  (not  to  be  used  for  young  children). 

Hard  rubber. 

Keep  in  phenol  2  to  5  per  cent,  solution. 
Dishes,  knives,  forks,  spoons,  etc.,  boiled  for  half  an  hour  or  more. 

If  sent  out  of  sick  room  to  boil,  soak  in  5  per  cent,  phenol  half  an 

hour. 
Urinals,  bed-pans,  sputum  cups,  rectal  tubes;  disinfect  and  allow  to 

stand  in  1-20  phenol. 
Bed-linen,  night  dresses,  towels,  handkerchiefs,  etc. 

Soak  over  night  in  2  to  5  per  cent,  phenol,  then  boil  for  half  an 

hour  before  sending  to  the  wash. 
Discharges  from  mouth,  nose,  ears  caught  in  pieces  of  gauze  or  cloth 

and  burned. 

Domestic  pets  excluded. 
Books,  toys,  etc.,  destroyed  after  illness. 

Temperature  of  room. 

Cold  air  desirable  if  the  body  is  well  protected. 
When  body  is  exposed  for  any  purpose  temperature  should  be 
at  70°  F. 

Bed. 

For  technique  of  bed-making,  see  Chap.  IX. 

Patient. 

Keep  in  bed  no  matter  how  mild  the  case  may  be,  especially  on 
account  of  the  kidneys. 

Sponge  bath  with  tepid  water  daily.  In  a  warm  room,  under  a  blan- 
ket, exposing  one  part  after  another. 

Nightgown. 

Should  be  flannel  or  cotton  or  silk  undervest  under  the  flannel 
nightgown. 

Diet. 

Person  preparing  food  for  family  should  not  come  into  contact  with 

patient. 

Nurse  should  not  handle  general  food  supply  of  family. 
For  fundamental  principles  see  Chap.  II. 
Do  not  push  feeding  in  first  few  days. 
Milk. 

Milk  has  proven  empirically  to  be  the  best  article  of  diet  in  scarlet 
fever.    Two  quarts  of  milk  equal  1,280  calories;  adding  1  ounce 
of  cream  and  J^  ounce  of  milk  sugar  to  each  glass  of  milk  in- 
creases the  caloric  value  to  2,000. 
Milk  modifications,  such  as  koumys,  buttermilk,  whey,  may  be 

substituted  in  part  or  in  whole. 

Cereals  and  cereal  gruels,  arrowroot,  rice,  barley,  cornstarch,  wheat 
flour,  farina,  imperial  granum,  jellies  of  barley  flour,  tapioca, 
sago.  Vanilla  ice  cream. 


430  TREATMENT  OF  ACUTE  INFECTIOUS  DISEASES 

Feed  at  two-hour  intervals.    Do  not  interrupt  sleep  at  night. 

For  caloric  values  see  text. 

After  the  period  for  nephritis  has  passed,  add  eggs,  custard,  potatoes, 

other  vegetables,  oysters,  fish  and  finally  meat. 
Give  no  meat  soups. 
Drinks. 

Water  freely. 

Lemonade,  orangeade,  juice  of  grape-fruit,  grape  juice. 

Imperial  drink  (cream  of  tartar,  a  tablespoonful  to  3  pints  of 
boiling  water,  add  sugar  and  lemon  juice  to  suit  taste). 

Give  2  quarts  or  more  of  fluid  a  day. 

Offer  water  every  hour. 

Care  of  skin. 

Sponge  bath  with  tepid  water  once  or  twice  a  day. 
Itching  and  burning. 

Cocoa  butter. 

Cold  cream. 

Sponge  with  sodium  bicarbonate  3i-0iii  (4  Gm.-l,500  c.c.). 

Bran  bath.  Handful  of  common  bran  in  a  clean  cloth  or  muslin 
bag,  swished  about  in  1  gallon  (4,000  c.c.)  water  until  slightly 
milky. 

Calamine  3i  (4  Gm.)  to  1  pint  (500  c.c.)  of  lime  water. 

Severe  itching,  1  per  cent,  or  2  per  cent,  phenol  in  olive  oil;  }/£  per 

cent,  dilution  of  liquor  cresolis  compositus  (Sturtevant) . 
Desquamation. 

Cocoa  butter. 

Vaseline  (petrolatum)  may  add 

Phenol  1  per  cent,  or  2  per  cent,  if  itching  is  severe. 

Soaking  hands  and  feet  in  warm  water. 

Do  not  pick,  rub  or  scrape  skin;  may  cause  infection. 
Apply  to  soles  of  feet  over  night  6  per  cent,  salicylic  acid  ointment 

(Sturtevant) . 
Itching  of  scalp. 

Wash  with  alcohol,  rub  in  white  vaseline  (Sturtevant). 

Care  of  mouth. 
Cleansing  solutions. 

Physiological  salt  solution  (3i-0i)  (4  Gm.-500  c.c.). 
Boric  acid  solution  2  per  cent,  to  4  per  cent. 
Dobell's  solution  (Sod.  bicarb,  and  borax  aa  3ii~0i  (8  c.c.-500  c.c.) 

with  about  1/3  per  cent,  phenol)  quarter  to  half  strength. 
Rinse  the  mouth  with  one  of  the  solutions  after  each  feeding. 
Dead  spaces  between  cheeks  and  teeth  searched. 
Teeth  cleansed;  interstices  freed  from  food;  use  cotton  swab  on 

wooden  tooth  picks,  soaked  with  a  cleansing  solution. 
Coated  tongue  and  sordes  on  lips  and  teeth,  one-half  strength  peroxide 

of  hydrogen  (official)  to  soften,  then  cleansing  solution. 
Scrape  tongue  with  edge  of  whalebone  after  coat  is  softened. 
Very  dry  mouth. 


SCARLET  FEVER  431 

Two  per  cent,  boric  acid  solution  and  liquid  petrolatum  (albolene) 

equal  parts;  add  lemon  juice  to  flavor. 
Fetid  breath,  foul  mouth,  stomatitis. 
Apply  following  solution: 

I* 
Phenol  (water  solution  1-20). 

Glycerin. aa  3i  (4  c.c.) 

Boric  Acid  (saturated  watery  solution) gviii        (240  c.c.) 

Follow  this  with  a  milder  solution  as  above. 

Care  of  nose. 

Dried  secretions  softened  with  olive  oil  or  vaseline. 
Follow  with  cleansing  solutions  on  cotton  swabs  or  as  a  sprav. 
Do  not  use  irrigations. 

Care  of  throat. 

Spray  with  cleansing  solutions. 
Irrigate  with  hot  physiological  salt  solutions  (110°  F.)  or  4  per  cent. 

sod.  bicarb,  solution.    Bag  a  foot  above  the  bed. 
Gargles  of  little  use. 
For  Angina,  see  below. 

Care  of  eyes. 

Cleansed  with  boric  acid  solution,  2  per  cent,  to  4  per  cent. 
Conjunctivitis. 

Cleanse  with  boric  acid  solution;  drop  a  drop  of  epinephrin  (adrenalin) 
chloride  in  eye  and  follow  with  5  per  cent,  to  10  per  cent,  argyrol. 

Care  of  genitals. 

Nurse  or  physician  should  inspect  them  each  day. 
Use  boric  acid  solution,  2  to  4  per  cent. 

Care  of  bowels. 
When  first  seen. 

Calomel,  gr.  %  (0.015  Gm.)  every  quarter  hour  for  five  or  six  doses 

r(well  borne  by  children). 
Follow  with  salts  in  three  to  four  hours;  in  adults  Epsom,  Rochelle 

or  Glauber's  gss.-i  (15-30  Gm.)  in  one-quarter  glass  of  water. 
In  children  follow  in  two  hours  with 
Milk  of  Magnesia  gss.  (15  c.c.). 
Liquor  Magnesii  Citratis  5vi-viii  (180-240  c.c.). 
Rochelle  Salt  3ii  (8  Gm.)  in  one-half  glass  of  water. 
Later  keep  open  with  enemata  or  mild  cathartic,  Liq.  magnesii 
citratis,  Hunyadi  water  or  cascara. 

For  nausea. 
The  calomel  in  divided  doses  as  above. 

Sodium  Bicarbonate gr.  xv       (1  Gm.)  in  5"  (60  c.c.)  water,  or 

Bismuth  Subnitrate gr.  xv       (1  Gm.),  or 

Cerium  Oxalate gr.  v         (0.30  Gm.)  or  in  combination,  e.  g. 


432  TREATMENT  OF  ACUTE  INFECTIOUS  DISEASES 


Bismuth  Subnitratis  .........................  gr.  xv        1  . 

Sodii  Bicarbonatis  ...........................  gr.  x          0  .  60 

Cerii  Oxalatis  ...............................  gr.  v         0.30 

M.    Give  one  such,  stirred  in  a  little  .water,  every  two  hours. 

When  severe: 
Large  dose  of  Bismuth  Subnitrate,  e.  g. 

Subnitrate  of  bismuth  3i  <4  Gm.) 
Six  drops  of  1  per  cent,  cocaine  hydrochloride  in  a  wine-glass  of 

water  every  fifteen  minutes  for  four  doses  (Sturtevant). 

Treatment  of  fever. 

Is  largely  treatment  of  toxemia. 
Treatment  of  pyrexia  per  se. 
When  temperature  is  excessive,  hyperpyrexia. 
When  long  sustained  above  104°  F. 

Cold. 

Infants,  sponge  baths. 

Children,  cold  packs  and  sponge  baths. 

Early  or  middle  adult  life,  the  bath  or  cold  pack. 

With  children  begin  with  relatively  warm  water  95°  F.  to  90°  F. 

and  increase  the  cold  to  80°  F.  to  75°  F.  to  70°  F.  or  colder. 
Discontinue  the  bath  or  pack  when  patient's  temperature  is  102°  F. 
If  patient  shows  evidence  of  collapse  stop  the  bath,  wrap  patient 

in  dry  blanket;  apply  heat  to  extremities.    Give  hot  drinks. 

Treatment  of  angina. 

When  membrane  is  present  always  take  culture  for  diphtheria  bacillus. 
If  culture  cannot  be  taken,  give  10,000  units  of  diphtheria  anti-toxin. 
If  case  is  very  severe  and  no  culture  can  be  taken  treat  as  a  case  of 

diphtheria.    If  laryngeal  symptoms  are  present  it  is  pretty  surely 

diphtheria.     Take  culture,  but  do  not  wait  for  return  but  give 

diphtheria  antitoxin  10,000  units  and  repeat  in  eight  or  six  or 

four  hours,  according  to  severity.    Keep  the  throat  clean  but  use 

the  mildest  solutions.  Do  not  use  astringents. 
Avoid  injury  to  throat  by  solutions  or  procedure. 
Solutions. 

Sodium  Chloride  3i-0i  (4  Gm.-  500  c.c.). 

Two  per  cent,  to  4  per  cent,  boric  acid  solution;  half  to  quarter 

strength  Dobell's  solution. 
Mode  of  application. 

Irrigations,  gargles,  sprays,  topical  application  with  swabs. 

Inhalation. 

Irrigation  with  hot  salt  solution  the  best. 
Boric  acid  and  Dobell's  solution  can  be  used  in  the  same  way. 
If  there  is  much  tenacious  mucus  give 

Preliminary  irrigation  or  spray  with 
Sodium  bicarbonate  solution,  gr.  xx  (1.30  Gm.)  to  5i  (30  c.c.) 


SCARLET  FEVER  433 

or 

Sodii  Bicarbonatis. 

Sodii  Biboratis aa  gr.  xxxii          (2.00) 

Aq.  Destillat.q.  s.  ad 5iv  (120.00) 

If  there  is  much  membrane  apply  gently  peroxide  of  hydrogen  with  a 
swab  or  an  applicator. 

Use  full  strength  (official)  or  spray  with  same  diluted  one,  two  or 
three  times. 

Then  follow  with  alkaline  irrigation  as  above  to  clear  mucus. 

Then  follow  with  hot  saline  solution  as  above. 

To  afford  comfort.  Apply  between  the  irrigations  sprays  of  any  of 
the  cleansing  solutions  named. 

Inhalations  of  hot  steam,  medicated  with  compound  tincture  of 
benzoin  or  oil  of  eucalyptus  or  oil  of  pine.  3i  (4  c.c.)  of  any  of  these 
on  hot  water  or  on  sponge  of  croup  kettle  amount  of  water  indif- 
ferent. 

Use  croup  kettle. 

Simple  inhalers. 

Common  kettle  with  cone  of  paper  attached  to  spout. 

Pitcher  of  hot  water  with  cone  of  paper  over  opening. 

Gargles  far  less  efficacious  than  other  methods. 

Use  same  cleansing  solutions  named. 

Cracked  ice. 

Cold  applied  to  neck  as  compresses. 
Coils. 
Ice-bags  (throat-bags). 

Heat  applied  to  neck. 

Fomentations.  (See  Chap.  IX  or  XIV.)  (Modify  to  sirit  site  of  ap- 
plication.) 

Gangrenous  cases 

Irrigate  with  potassium  permanganate  solution  1-2,000. 

(Other  suggestions  in  gangrenous  cases  have  been, 
Sprays  of  adrenalin. 

Gargles  of  alcohol  diluted  six  to  eight  times. 
Touching  with  Tr.  Iodine. 

Application  of  Loffler's  solution  once  or  twice  a  day.) 

Rhinitis. 

Cleansing  solutions  same  as  throat. 
Sprays  best,  or  swab. 

Do  not  use  irrigations  unless  specially  indicated. 
If  membrane  is  present,  smear  and  culture  for  diphtheria. 

Spray  with  peroxide  of  hydrogen  diluted  three  or  four  times. 

Then  use  cleansing  spray. 
When  nares  are  blocked  or  purulent  discharge  is  profuse,  irrigate. 

(For  procedure,  see  text.) 

Late  Rhinitis,  muco-purulent,  sero-purulent  or  severe. 
Is  infectious. 
Same  measures  of  cleanliness. 


434  TREATMENT  OF  ACUTE  INFECTIOUS  DISEASES 

Staphylococcus  aureus  usually  present. 
Vaccines. 

50,000,000  first  dose. 

100,000,000 

200,000,000 

300,000,000 
Twice  a  week. 

Usually  three  or  four  doses  enough. 
If  temperature  continues  think  of  sinuses. 

Circulatory  failure. 
Digitalis. 

If  the  need  is  immediate  and  urgent  give 
Strophanthin  (Boehringer  preferred),  gr.  1/120-1/60  (0.0005-0.001 

Gm.)  into  muscle. 
This  dose  should  not  be  repeated  more  than  once,  at  an  interval 

of  twelve  hours. 
Follow  the  first  dose  by  digitalis,  either  the  infusion,  the  tincture 

or  the  leaf. 

Give  three  or  four  times  a  day. 
Dose. 

Infusion 5  ss.  (15  c.c.) 

Tincture m.  xxx  (2  c.c.) 

Leaf gr.  iii  (0.20  Gm.) 

This  is  a  daily  dose  of  9-12  grains  (0.60-0.80  Gm). 

Keep  this  up  for  twelve  to  fifteen  doses  (three  to  four  days)  or 
until  desired  results  are  obtained  or  some  evidences  of  toxicity 
obtain. 

Child  of  five  years,  a  quarter  dose. 
If  not  urgent  omit  strophanthin.    Begin  with  digitalis. 
I  am  becoming  more  and  more  convinced  of  the  value  of  digitalis  in 
circulatory  failure  of  acute  infections  and  am  giving  it  preference 
to  the  vaso-motor  stimulants  mentioned. 
(See  Pneumonia,  Chap.  IX.) 
Usually  vaso-motor. 
Vaso-motor  stimulants. 
Caffeine. 
Soluble  double  salt  of  sodium  salicylate  or  sodium  benzoate  and 

caffeine. 

Adult  dose,  gr.  v  (0.30  Gm.)  into  muscle. 
Child  of  five  years,  gr.  ss.-i  (0.030-0.060  Gm.). 
Child  of  eleven  years,  gr.  i-ii  (0.060-0.13  Gm.). 
Frequency  every  four,  three  or  two  hours. 
Camphor. 
In  solution  in  olive  oil  or  sesame  oil  10  per  cent,  or  20  per  cent. 

never  in  paraffin  oil;  or  in  ether,  10  per  cent. 
Adult  dose,  gr.  iii-v  (0.20-0.30  Gm.). 
Child  of  five  years,  gr.  ss.-i  (0.030-0.060  Gm.). 


SCARLET  FEVER  435 

Child  of  eleven  years,  gr.  i-ii  (0.060-0.130  Gm.). 

Give  hypodermically  or  intramuscularly. 

Frequency  every  four,  three  or  two  hours. 
Caffeine  and  camphor  alternately. 
Strychnine  sulphate  or  nitrate. 

Adult  dose,  gr.  1/60-1/30  (0.001-0.002  Gm.). 

Child  five  years,  gr.  1/200-1/150  (0.0003-0.00045  Gm.) 

Child  eleven  years,  gr.  1/100-1/80  (0.0006-0.0008  Gm.). 
Adrenalin  (epinephrin). 

In  collapse. 

Give  intramuscularly,  1 :1000  solution. 

Dose  m.  x  (0.60  c.c.). 

or 

Intravenously  m.  ii-iii  (0.150-0.20  Gm.). 

At  ten  years,  a  half  dose. 

At  five  years,  a  quarter  dose. 

Nervous  symptoms. 

Stupor  and  delirium. 
Cold  air. 
Cold  water. 
Sponges. 
Packs. 
Baths. 
Ice-bag  or  coil  to  head. 

Restlessness. 

Bromides  of  potash,  sodium,  or  ammonium  or  a  mixture  of  equal 

parts  of  each. 
Dose,  gr.  xv-xx  (1-1.30  Gm.)  three  or  four  times  a  day  for  adults; 

gr.  iii-v  (0.20-0.30  Gm.)  three  or  four  times  a  day  for  children. 
Phenacetin,  gr.  i-ii  (0.060-0.130  Gm.)  at  four-hour  intervals  may 

be  given  to  children. 

Sleeplessness. 

Cold  baths. 

Cold  sponges. 

Warm  sponges. 

Bromides.    (See  restlessness.) 

Phenacetin.    (See  restlessness.) 

Trional,  gr.  x-xv  (0.60-1  Gm.)  in  capsules  or  in  a  little  warm 

water  or  wine,  whisky  or  brandy. 
Repeat  in  two  hours  if  needed  (adult) . 
Chloralamid,  gr.  xx-gr.  xxx  (1.30-2  Gm.)  in  powder,  cold  water 

or  wine,  whisky  or  brandy,  and  repeat  in  two  hours  if  needed 

(adult). 
Wild  delirium. 
Morphine  sulphate,  gr.  1/8  (0.008  Gm.)  hypodermically  for  adult; 

gr.  1/48-1/24  (0.0015-0.003  Gm.)  for  child. 


436  TREATMENT  OF  ACUTE  INFECTIOUS  DISEASES 

Specific  treatment. 
Convalescent  serum.  1 
Convalescent  blood.    !•  (See  text.) 
Normal  human  blood,    j 
Vaccines. 

Indicated  in  some  of  the  subacute  and  chronic  streptococcus  com- 
plications of  the  disease.    (See  below.) 
Polyvalent  sera. 
Moser  serum. 
New  York  Board  of  Health  serum.    (See  text.) 

Otitis. 

Examine  ears  daily. 

With  involvement  of  drum.    (See  text.) 
Incise. 

For  technique  and  after  care,  see  text. 
Earache. 

Dry  heat,  to  avoid  maceration  of  drum. 

Hot  salt  bag. 


Hot  water  bag. 


Applied  to  the  ear. 


Hot  plate. 

Take  a  wine-glass  made  hot  by  dipping  into  hot  water,  put  in  a 
pledget  of  cotton;  in  this  10-20  drops  of  chloroform;  apply  in- 
verted glass  over  ear.  (Yeo.) 

Drop  into  ear  two  or  three  drops  of  5  per  cent,  phenol  in  glycerin. 

If  irrigations  are  used,  use  hot  water  first  and  drop  in  4  per  cent, 
cocaine  hydrochloride  solution  after. 

Mastoid.    (See  text  for  symptoms.) 
Surgical  procedure. 

Remember  that  the  discharges  from  the  ear  are  highly  infectious. 
Destroy  by  burning  or   1-20  carbolic  or  1-1,000  bichloride  of 
mercury. 

Sinus  involvement.       0       .    , 

f  Surgical  procedure. 
Cerebral  abscess.      J 

Vaccine  treatment  of  discharge  from  ear. 

Determine  organism  by  culture. 
It  may  be  staphylococcus  aureus. 

Staphylococcus  albus. 

Bacillus  pseudo-diphtheriae. 

Bacillus  pyocyaneus. 

Streptococcus  pyogenes. 

Vaccine  should  be  autogenous  when  possible  and  should  be  fresh. 
Time  to  begin  8th  to  16th  day  of  discharge. 
Contraindications. 

High  fever. 

Nephritis. 


SCARLET  FEVER  437 

Toxemia. 

Inter  current  affections. 
Dose  beginning. 

Streptococcus      5,000,000. 

Staphylococcus  20,000,000. 
Increase  depends  on  reaction;  no  reaction,  double  each  dose  for 

three  or  four  doses;  then  add  20,000,000-30,000,000  streptococci 

at  a  dose;  50,000,000-100,000,000  staphylococci  at  a  dose. 
Frequency,  twice  a  week  or  every  five  or  six  days. 
Duration,  six  to  twelve  doses. 
Reaction.    (See  text.) 

Adenitis. 

The  severe  suppurating  forms  are  later  manifestations,  third  or 

fourth  week  or  later. 
Cold. 

Ice  bags  or  bladders. 

Ichthyol,  25  per  cent,  in  vaseline  to  pure  product  painted  on. 
Heat. 

Fomentations.!  /CI  .      . 

Poultices.         }  (See  to**  «  to  value') 
Wet  dressings. 

Huge,  very  wet  dressings  at  the  temperature  of  melting  ice. 

Use  following  solution  for  dressings. 

Plumbi  Acetatis 60  5ii 

Alu minis  Pulveris 60  5ii 

Alcoholis 250  gviii 

Glycerini 120  giv 

Aquae 1,000  Oii 

M.  et.    Shake.    (Sturtevant.) 

At  the  first  sign  of  suppuration  incise. 

Arthritis. 

Usually  in  second  week. 

Treat  as  in  rheumatism.    (See  Chap.  III.) 

Suppuration  is  rare. 

Treat  on  surgical  principles.    (See  text.) 

Myositis. 
Local  treatment  and  medication  as  in  arthritis. 

Nephritis. 

Examine  urine  daily.    Keep  reagents  for  albumin  test  at  the  patient's. 
Severe  attacks  occur  late  in  third  or  early  in  fourth  week. 
Prophylactic. 

Good  nursing. 

Bed  during  convalescence. 

Avoidance  of  draughts. 

Diet  largely  of  milk. 


438  TREATMENT  OF  ACUTE  INFECTIOUS  DISEASES 

Treatment. 

1.  Rest  to  the  functions  of  the  kidney. 

2.  Treat  symptoms. 

3.  Support  patient. 
Patient  is  put  between  blankets. 
Flannel  nightgown. 

Diet. 

If  explosive  with  nausea  and  vomiting  give  only  cracked  ice  until 
these  symptoms  subside. 

Suppression  or  oliguria. 

No  more  water  than  the  kidney  eliminates. 
Food,  only  sugar  added  to  water  or  fruit  juices. 
Increase  water  intake  as  urine  output  increases. 
Then  begin  to  add  milk  tentatively,  observing  effect  on  total  output 
of  urine  and  albumin. 

(Edema. 

Make  all  articles  salt-free;  salt-free  bread,  salt-free  butter.     With 
increasing  oedema  cut  down  water  intake. 

Diet  outlined  for  Scarlet  Fever. 

Milk  and  cereals,  bread  and  butter,  are  suitable  for  the  nephritis. 
Drinks. 

Plain  water,  mineral  waters  (no  sodium  chloride)  lemonade,  orange- 
ade, Imperial  drink. 

Amount  not  more  than  1  pint  to  1^  pints  more  than  urine  out- 
put. 

Purgation. 

Fairly  copious  watery  movements  by  salts. 
Rochelle,  Epsom  or  Glauber's  salt,  or  sodium  phosphate. 
Dose,  §ss.-i  (15-30  Gm.)  in  three-quarter  glass  of  water  for  adults, 

half  this  dose  for  children, 
or 

Compound  Jalap  powder,  5i  in  warm  water  (adult  dose). 
Purgation  must  not  induce  fatigue. 

Diaphoresis. 

Hot  pack  once  or  twice  a  day.    (Technique,  see  text.) 
Hot  air  bath.    (Technique,  see  text.) 
Hot  bath. 
Begin  at  95°  F.  for  ten  or  fifteen  minutes.    Then  wrap  in  a  dry 

or  hot  moist  blanket  or  pack  for  another  half-hour. 
Drugs. 
Pttocarpine,  only  when  pack  is  not  attainable,  has  its  dangers. 

(See  text.) 
Cupping. 

Especially  indicated  in  early  stages  of  congestion  and  acute  sup- 
pression; two  or  more  cups  over  either  kidney  for  fifteen  to 
twenty  minutes  or  until  capillaries  are  well  dilated.  (For  tech- 
nique, see  Chap.  IX.) 


SCARLET  FEVER  439 

Counterirritation  . 

Hot  poultices.  (For  technique,  see  Chap.  IX.) 
Fomentations.  (For  technique,  see  Chap.  IX.) 
Mustard  paste.  (For  technique,  see  Chap.  IX.) 

Diuresis. 

After  acutest  stages  have  passed. 
Mildest  diuretics  first. 

Water  and  drinks  mentioned,  milk. 

Then  alkaline  salts. 

Potassium  citrate. 

Potassium  acetate. 

Potassium  bicarbonate. 

Sodium  bicarbonate. 

Any  one  or  combination. 

Dose,  gr.  xx-xxx  (1.30-2  Gm.)  every  two  to  three  hours. 

Children  half  dose. 

Continue  until  urine  reacts  alkaline;  then  reduce  dose  in  frequency, 

but  keep  urine  just  alkaline. 
Little  later. 

Diuretin,  gr.  v-x  (0.30-0.60  Gm.)  three  times  a  day. 

(The  smaller  dose  in  children  or  even  half  this.) 
Agurin. 

Same  dose  and  frequency  as  diuretin. 
Theocin.    Same  frequency  as  diuretin  for  one  day  only.    Dose  gr.  v 

(0.35  Gm.)  adult. 
Caffeine;  especially  if  the  heart  is  weak. 

Use  double  salt  of  sodium  salicylate  or  sodium  benzoate  or  citrated 
caffeine. 

Dose,  ii-v  (0.20-0.30  Gm.). 

Frequency,  three  times  a  day. 

Child  of  five  years,  dose,  gr.  i-gr.  ii  (0.060-0.120  Gm.)  three  or 
four  times  a  day. 

(Edema. 

Diaphoresis.  ] 

Diuresis.        [  (See  above.) 

Purgation. 

Hydrothorax,  paracentesis. 

Ascites,  paracentesis. 

Anascara,  scarification. 

Southey's  tubes.    (For  technique,  see  text.) 

Uraemia. 

ee  above.)  « 


Hypertension  and  twitching  foretelling  convulsions. 
Venesection. 
Adult,  10  to  20  ounces. 
Child  (five  years),  3  to  6  ounces. 


440  TREATMENT  OF  ACUTE  INFECTIOUS  DISEASES 

Sedatives. 

Chloral  by  rectum. 

Dose,  gr.  xxx-3i  (2-4  Gm.). 

Child  (five  years),  gr.  v-gr.  x  (0.30-0.60  Gm.). 

Give  in  2  ounces  of  warm  milk  or  starch  paste. 

Repeat  in  two  hours  if  needed. 

Convulsions. 
During  the  convulsion. 

Chloroform  inhalation  until  the  attack  ceases. 
Follow  at  once  by 

Morphine  sulphate,  gr.  1/4  (0.015  Gm.). 
Repeat  in  half  hour  if  needed. 

Child  (even  infant),  gr.  1/48-gr.  1/24  (0.0015-0.0030  Gm.). 
Repeat  in  an  hour  if  needed. 

Enteroclysis. 

Salt  solution,  5i-0i  (4  Gm.-500  c.c.)  2  quarts  (2  litres)  at  104°  F.- 
108°  F.  several  times  a  day. 

Lumbar  puncture. 

(Technique,  see  Cerebro-spinal  Meningitis,  Chap.  XXV.) 


Hypertension. 

Nitroglycerin,  gr.  1/100-gr.  1/50  (0.0006-0.0015  Gm.)  every  two  hours. 
Child  of  five  years,  gr.  1/200  (0.0003  Gm.). 


Headache. 

Ice  bag  to  head  and  nape  of  neck. 

Acetphenetidin  (Phenacetin)  cautiously,  gr.  v  (0.30  Gm.)  every  hour 

for  three  or  four  doses. 
Child,  gr.  i-iss.  (0.060-0.10  Gm.). 
When  excruciating,  lumbar  puncture. 

Nausea  and  vomiting. 

Cracked  ice. 

Mustard  paste  to  epigastrium  1-4,  5,  or  6  of  flour. 

For  technique,  see  Chap.  IX. 

Bismuth,  gr.  x-xy-lx  (0.60-1-4  Gm.). 

Sodii  bicarbonatis,  gr.  v-lx  (0.30-4  Gm.). 

Oxalate  of  cerium,  gr.  iii-v  (0.20-0.30  Gm.). 

Or  combined  as 


Bismuth  Subnitratis  ......................  15         (5ss.) 

Sodii  Bicarbonatis  ........................  10         (Siiss.) 

Cerii  Oxalatis  ............................  5         (gr.  Ixxv) 

M.  et  div.  in  chart  no.  xv. 

One  in  a  little  water  or  milk  every  two  hours. 


SCARLET  FEVER  441 

Pneumonia. 


Pericarditis, 
Treat  as  primary. 

Anemia. 

In  convalescence  give  iron, 
Blaud's  pill  (pil.  ferri  carbonatis), 
or 

Vallet's  mass  (massae  ferri  carbonatis), 
gr.  iii-v  (0.20-0.30  Gm.)  three  times  a  day.    (Adult  dose.) 
Basham's  mixture  (liq.  ferri  et  ammonii  acetatis),  5i-iv  (4-15  c.c.). 

Convalescence  from  nephritis. 

Remain  in  bed  until  albuminuria  ceases,  or  for  four  to  five  weeks. 

After  that  allow  up  tentatively,  then  about  house,  then  out  of  doors. 

Watch  effects  on  albumin,  casts,  and  total  quantity. 

If  aggravated,  put  back  to  bed. 

Wear  woolen  underclothing. 

Adapt  clothing  to  weather. 

Avoid  exposure  to  weather. 

Change  wet  clothing  at  once. 

Watch  kidneys  on  occasion  of  any  illness. 

Examine  urine  every  three  to  six  months. 

Other  complications. 

Endocarditis.!  r»or 

Pericarditis.   I  *    re> 

Treat  as  under  other  circumstances. 

(See  Rheumatic  Fever,  Chap.  III.) 

Bronchopneumonia. 

Treatment.     (See  Pneumonia,  Chap.  IX  and  Streptococcus  Pneu- 
monia, Chap.  X.) 

Pleurisy. 
Treatment.    (See  Pneumonia,  Chap.  IX.) 

Noma. 

Application  of  bismuth  subnitrate  and  water  to  form  thick  paste; 
apply  several  times  a  day. 

Curetting. 

Fuming  nitric  acid  application,  excision. 

Relapses. 
Treat  like  initial  attack. 

Discharge  of  patient. 
Four  weeks  in  the  mildest  case. 
Six  weeks  is  safer. 


442  TREATMENT  OF  ACUTE  INFECTIOUS  DISEASES 

If  still  desquamating  at  the  end  of  six  weeks,  isolation  must  continue 

until  desquamation  ceases. 
If  nose,  ears  or  glands  are  discharging  when  desquamation  ceases 

isolation  must  continue  still  until  the  discharges  cease. 
When  patient  is  released  from  quarantine,  he  must  not  mingle  with 

other  children  for  a  month  after. 

Should  not  sleep  with  other  children  for  three  months  (Holt). 
Preparation  of  the  child  for  release. 
Soap  and  water  bath,  then  carbolic  acid  (phenol)  solution  (1-50) 

bath, 
or 

Bichloride  of  mercury  bath  (1-5000). 
Head  shampooed. 
Northrop's  rules. 

1.  Ears  irrigated  with  bichloride  1-8000. 

2.  Scalp  shampooed  with  soap  and  water. 

3.  Scalp  shampooed  with  bichloride  1-2000. 

4.  Tub  bath  of  soap  and  water. 

5.  Tub  bath  of  bichloride  1-8000  for  twenty  minutes. 

6.  Sponge  bath  of  bichloride  1-2000. 

7.  Bichloride  sponged  off  with  sterile  water. 

8.  Nasal  spray  of  bichloride  1-8000. 

9.  Mouth  cleansed  with  saturated  solution  of  boric  acid. 
10.  Taken  to  a  clean  room  and  clad  in  clean  clothes. 


Fumigation  and  sterilization. 

(For  discussion,  see  text.) 

Washable  clothing  boiled  one  hour. 

Mattresses,  pillow,  heavy  blankets,  etc.,  sterilized  by  steam  under 

pressure. 

Toys.    Always  destroy;  never  attempt  to  sterilize. 
Metal  objects.    Sterilize  in  1-20  phenol. 

Room.    Smooth  walls,  woodwork  and  floors  washed  with  1-2000  bi- 
chloride, then 

Fumigated  with  formaldehyde  or  sulphur. 
Formaldehyde  best. 

Obtain  skilled  assistance  when  possible;  otherwise  seal  room,  win- 
dows and  doors  with  strips  of  paper  glued  together  by  mucilage 
of  tragacanth  over  cracks. 

Burn  formaldehyde  candles  or  use  other  generator. 

Must  be  burned  in  presence  of  moisture  (water  over  alcohol  lamp). 

Sulphur  less  reliable  and  more  injurious  to  fabrics. 
After  fumigation. 

Repaper,  repaint  and  rekalsomine. 


CHAPTER  XVIII 

DIPHTHERIA 

SINCE  the  genius  of  Jenner  made  the  treatment  of  Smallpox  a  rare 
experience  for  the  general  practitioner,  no  other  triumph  of  medicine  is 
comparable  to  serum-therapy  in  Diphtheria.  Where  four  children  died 
before  the  introduction  of  diphtheria  antitoxin,  but  one  dies  to-day 
and  the  statistics  that  show  a  fall  in  mortality  from  40  per  cent,  in  pre- 
antitoxin  days  to  10  per  cent,  at  the  present  do  but  scant  justice  to  the 
efficacy  of  this  treatment,  because  so  much  depends  on  the  promptness 
and  mode  of  administration  of  antitoxin,  that  the  figures  are  vitiated  by 
the  neglected  cases.  More  recently  the  method  devised  by  Schick  to 
determine  beforehand  what  individuals  are  susceptible  to  diphtheria 
and  the  mode  of  inducing  active  immunity  lessen  still  further  the  terrors 
of  this  dread  disease. 

While  the  organism  responsible  for  the  disease  may  be  found  in  a 
certain  per  cent,  of  cases  distributed  to  various  organs  of  the  body,  the 
disease  can  scarcely  be  called  a  septicaemia,  but  essentially  a  toxemia,  the 
toxins  in  which  are  elaborated  at  the  site  of  the  membrane  formation  in 
the  upper  air-passages. 

Success  in  treatment  depends  essentially  on  an  early  appreciation 
of  the  condition  and  an  early  appreciation  can  be  had  only  by  a  fidelity 
to  thoroughness  in  routine  procedure.  The  early  symptoms  are  not 
distinctive;  a  malaise,  a  headache,  a  chilliness  and  a  sore  throat;  but  the 
sore  throat  is  often  trivial  or  indeed  does  not  occur  and  in  infants  there  is 
little  to  suggest  that  the  throat  is  the  seat  of  the  trouble. 

Malaise,  a  little  temperature  and  a  depression  and  apathy  out 
of  proportion  to  the  temperature  may  be  all  the  child  offers  to  one's 
observation.  The  finding  of  the  local  lesion  comes,  then,  often  enough  as 
a  surprise,  awarding  the  routine  of  examination  of  the  throat. 

There  are  two  examinations  too  often  overlooked  or  slurred  that 
should  be  made  in  every  instance  of  infection  in  infancy,  unless  the 
lesion  is  more  than  obvious  and  even  then,  in  search  of  complications; 
namely,  the  ear  and  the  throat.  Humiliation  comes  to  almost  every 
man  who  wilfully  or  inadvertently  overlooks  these  procedures. 

In  the  case  of  the  ear  not  a  little  skill  is  needed  to  see  at  all  or  intelli- 
gently with  the  older  otoscopes,  but  with  the  more  modern  magnifying 
otoscopes,  changes  in  the  ear  can  be  scarcely  overlooked.  The  examina- 


444  TREATMENT  OF  ACUTE  INFECTIOUS  DISEASES 

tion  of  the  throat  is  more  commonly  made,  but  is  often  a  meaningless 
convention,  carelessly  done.  In  the  infant  a  little  skill  in  placing  the 
depressor  well  back  on  the  tongue  gives  a  momentary,  but  excellent 
view;  but  often  this  is  insufficient  and  a  conscientious  examination  is  put 
off  rather  than  persist  with  the  crying  and  struggling  child.  The  tonsils, 
the  pillars  of  the  fauces  and  the  pharynx  must  be  seen. 

Such  a  routine  does  nob  allow  the  condition  to  be  overlooked. 

But  there  is  one  other  fact  on  which  much  emphasis  must  be  laid, 
namely,  that  diphtheria  may  be  present  when  the  clinician  is  quite  sure 
that  he  is  dealing  with  a  follicular  tonsillitis  and,  more,  diphtheria  may 
be  present  when  no  exudate,  membranous  or  follicular  is  evident  and 
hence,  in  any  inflammation  of  the  throat  in  a  child,  even  when  only 
catarrhal,  a  culture  should  be  made.  Again  and  especially  in  infants, 
nasal  diphtheria  may  be  present  when  no  membrane  is  anywhere  visible 
and  a  persistent  nasal  discharge,  particularly  if  excortiating  or  bloody 
should  demand  a  culture.  Finally,  a  laryngitis,  more  particularly  of 
a  croupy  character  and  certainly  if  persisting  in  the  daytime  should  make 
a  culture  imperative. 

The  Culture.  A  tube  of  fresh  culture  medium  must  be  ob- 
tained; the  suspected  parts  thoroughly  rubbed  with  the  swab,  the 
surface  of  the  medium  thoroughly  smeared  with  the  contaminated 
swab;  great  care  must  be  taken  to  bring  the  swab  into  contact  with  no 
other  object  in  the  procedure;  the  culture  submitted  to  a  competent 
bacteriologist  for  incubation  and  diagnosis. 

The  Family.  When  diphtheria  is  determined  in  any  one  indi- 
vidual, all  the  members  of  his  family  at  once  become  suspects.  The 
children  are  to  be  kept  from  school  and  adults  who  have  intimate  rela- 
tions with  children,  such  as  teachers,  should  temporarily  interrupt  their 
occupation. 

A  Schick  reaction  should  be  done  on  all  members  of  the  family  and 
those  who  react  positively  should  be  given  an  immunizing  dose  of  serum 
and  measures  taken  to  induce  active  immunization. 

Authorities  should  be  informed  of  the  case  and  inspection  of  the 
school  or  suspected  groups  of  people,  who  may  be  the  source  of  infection, 
should  be  made. 

Children  should  be  isolated  until  cultures  can  be  taken  from 
their  throats  and  a  report  made  on  the  cultures.  Adults  in  the  family 
should  submit  to  the  same  procedure.  In  this  way  those  who  are  ''car- 
riers" can  be  determined  and  can  be  kept  in  isolation  until  their  throats 
are  free  from  infection. 

All  the  children  in  the  family  who  react  to  Schick  should  be  immunized 
with  antitoxin,  500  units  for  the  infants  and  1,000  units  for  the  older 


DIPHTHERIA  445 

children  and  adults.  All  adults  in  intimate  contact  with  the  case  who 
react  positively  should  be  immunized. 

Children,  free  from  infection  as  proved  by  negative  cultures  and  with 
negative  Schick,  should  be  removed  from  the  house,  if  possible,  lest  they 
become  carriers.  It  is  wise  to  repeat  such  cultures  at  least  once.  The 
immunization  should  be  repeated  every  two  weeks  in  those  reacting 
positively  to  Schick  unless  active  immunization  is  practiced.  When  a 
Schick  reaction  cannot  be  practiced  all  the  children  of  the  household 
and  adults  in  close  contact  with  the  patient  should  receive  immunizing 
doses,  this  should  be  repeated  every  two  weeks  in  succession.  Children 
found  to  be  infected  or  to  be  carriers  should  be  isolated,  but  never  with 
the  sick  case,  and  the  isolation  of  these  cases  should  be  separate. 

The  Schick  Reaction.  This  reaction  depends  upon  the  fact  that 
if  diphtheria  toxin  is  introduced  into  the  skin  it  causes  an  irritation  in 
the  tissues  of  that  structure,  which  is  easily  recognized,  unless  there  is 
circulating  in  the  blood  and  tissue  juices  of  the  individual  inoculated 
antitoxin,  which,  neutralizing  the  toxin,  shelters  the  tissues  from  its 
noxious  action  and  thus  prevents  a  reaction. 

Briefly  then  a  (positive)  reaction  means  absence  of  antitoxin  or 
in  other  words  susceptibility  to  diphtheria;  an  absence  of  (negative) 
reaction  means  the  presence  of  antitoxin  or  immunity. 

This  important  contribution  to  the  warfare  upon  diphtheria  was 
made  by  Schick  in  1913. 

The  details  to  follow  are  derived  largely  from  the  publications  of 
the  Department  of  Health  of  the  City  of  New  York. 

Technique.  The  material  used  is  a  fresh  solution  of  diphtheria 
toxin  containing  1/50  the  minimum  lethal  dose  for  a  250  gram  guinea-pig. 
This  should  be  contained  in  0.2  c.c.  of  the  diluent.  How  to  attain 
such  proportion  should  be  found  in  instructions  accompanying  the 
material  furnished;  e.  g.,  the  Health  Department  of  the  City  of  New 
York  furnishes  the  toxin  in  capillary  tubes,  the  contents  of  which  when 
expelled  into  10  c.c.  of  a  normal  saline  affords  such  a  dilution  that  0.2  c.c. 
of  this  dilution  contains  the  desired  1/50  M.  L.  D.  (minimum  lethal  dose.) 
One  tube  will  answer  for  many  tests  and  the  saline  solution  will  keep 
12  hours  if  kept  cool  in  the  ice  box. 

The  syringe  used  should,  of  course,  be  graduated  to  fractions  of  a  c.c. 
such  as  a  ' 'Record"  or  a  Sub  Q.  tuberculin  syringe,  though  an  ordinary 
syringe  can  be  used  if  necessary.  A  fine  steel  or  platinum  iridium  needle 
is  selected,  a  #  26  gauge,  1/4  or  1/2  inch  in  length  is  excellent.  The  flexor 
surface  of  the  arm  chosen  and  prepared  by  cleansing  with  alcohol. 

The  injection  must  be  intradermal,  between  the  layers  of  the  skin, 
not  subcutaneous.  To  effect  this,  one  sees,  a  fine  needle  is  required  and 


446  TREATMENT  OF  ACUTE  INFECTIOUS  DISEASES 

its  insertion  should  be  so  superficial  that  one  may  see  the  oval  opening 
of  the  needle  through  this  superficial  layer  of  the  skin  and  the  injection 
fluid  should  raise  a  wheal  that  brings  out  pitting  of  the  openings  of  the 
hair  follicles.  ., 

The  positive  reaction  is  indicated  by  a  trace  of  redness  at  the  site 
of  the  injection  in  12  to  24  hours,  distinct  in  24  to  48  hours  and  at  its 
height  on  the  3rd  or  4th  day  when  it  presents  a  circumscribed  area  of 
redness  with  some  infiltration  one  to  two  centimeters  in  diameter.  This 
continues  for  7  to  14  days.  After  this  it  gradually  disappears  until  only  a 
brownish  scaling  area  is  left,  which  persists  for  3  to  6  weeks. 

The  negative  reaction  is  determined  by  failure  to  respond  to  the 
irritating  effects  of  the  toxin  and,  as  has  been  said,  means  immunity. 
Repeated  tests  over  a  period  of  years  makes  it  almost  certain  that  this 
natural  immunity  in  individuals  over  three  years  of  age  is  permanent. 

The  susceptibility  at  various  ages  to  diphtheria  as  determined  by  the 
Schick  reaction  is  shown  in  the  following  table  published  by  the  New 
York  Department  of  Health: 

Age  Susceptible 

Under  3  months 15% 

3  to  6  months 30% 

6  months  to  1  year 60% 

1  to  2  years 60% 

2  to  3  years 60% 

3  to  5  years 40% 

5  to  10  years 30% 

10  to  20  years 20% 

Over  20  years 12% 

The  low  susceptibility  under  6  is  attributable  to  antitoxin  from  the 
mother's  blood  still  persistent  in  that  of  the  infant. 

The  pseudo  reaction.  Unhappily  the  determination  of  a  positive 
reaction  is  embarrassed  by  another  reaction  in  the  skin  provoked 
not  by  the  diphtheria  toxin,  but  by  the  protein  substance  of  autolyzed 
diphtheria  bacilli  to  which  a  certain  number  of  individuals  are  anaphy- 
lactic.  It  is  easy  enough  to  state  differences  in  the  true  and  false  reac- 
tions; but  at  first,  before  the  eye  becomes  practiced,  the  differentiation 
may  present  difficulties. 

The  pseudo  reaction  occurs  earlier,  in  6  to  18  hours;  it  make  its 
full  development  in  36  to  48  hours  and  disappears  on  the  3rd  or  4th 
day.  It  leaves  a  little  brownish  discoloration  but  rarely  scales.  When  at 
its  height  it  shows  a  dusky  red  centre  with  a  secondary  areola;  it  some- 
what resembles  a  hive  (urticaria). 


DIPHTHERIA  447 

Patients  who  develop  only  this  false  reaction  are  immune.  It  has 
the  significance  of  a  negative  reaction. 

Here  again  we  are  met  with  the  annoying  fact  that  a  patient  may 
react  to  both  the  toxin  and  the  protein  of  the  autolyzed  bacilli;  that  is, 
he  may  show  a  combined  reaction.  This  combination  of  positive  and 
pseudo  reaction  shows  features  of  both.  There  is  more  central  redness 
and  more  infiltration;  the  pseudo  element  fades  and  leaves  the  brown, 
scaling  area  of  the  true. 

Control.  One  may  obtain  and  use  diphtheria  toxin  heated  at 
75°  C.  for  5  minutes  to  control  the  Schick  reaction.  This  heating  de- 
stroys the  toxin  but  not  the  protein  products  of  the  autolyzed  bacilli. 
This  is  diluted  in  saline  and  injected,  in  the  same  amount  and  manner 
as  the  toxin,  in  the  other  arm  or  far  enough  away  from  the  site  of  the 
other  injection  to  avoid  intermingling.  A  negative  reaction  to  the 
toxin  will  also  give  a  negative  reaction  to  the  heated  toxin.  A  positive 
reaction  only  to  the  toxin  will  give  a  negative  reaction  to  the  heated 
toxin. 

A  pseudo  reaction  to  the  toxin  will  give  also  a  pseudo  reaction  to  the 
heated  toxin  and  the  comparison  of  the  reactions  and  their  course  will 
determine  their  nature. 

A  combined  reaction  to  the  toxin  will  call  out  a  pseudo  reaction 
to  the  heated  toxin.  The  difference  in  character  and  course  of  the  two 
reactions  will  determine  their  nature. 

Of  course  the  control  may  be  used  after  the  unheated  toxin  has  given 
a  doubtful  reaction.  If  such  controls  are  not  used,  any  doubtful  case 
should  be  retested  or  failing  this  or  being  still  in  doubt,  any  doubtful 
reaction  should  be  treated  as  a  true  one. 

One  can  see  at  once  the  great  value  of  the  Schick  reaction;  how  readily 
in  hospitals,  institutions  and  schools  the  immunes  and  non-immunes 
can  be  separated;  what  a  great  saving  in  antitoxin  this  means;  how  it 
leads  to  preventive  treatment  of  the  non-immunes  and  what  a  relief 
it  must  afford  to  the  family  into  whose  midst  diphtheria  has  been 
brought. 

Active  Immunization.  This,  of  course,  is  practiced  on  those  only 
who  give  a  positive  reaction  to  the  Schick  test. 

It  is  brought  about  by  introducing  small  amounts  of  toxin  under  the 
skin,  which  provokes  the  formation  of  antitoxin.  Diphtheria  toxin, 
however,  is  so  virulent  that  very  small  quantities  carefully  given  and 
cautiously  increased,  necessitating  a  considerable  period  of  time  in 
its  performance,  are  alone  feasible;  but  fortunately,  it  was  found  that  if 
antitoxin  sufficient  to  neutralize  the  toxin  to  the  point  of  not  being 
poisonous  was  administered  with  it,  this  toxin-antitoxin  combination 


448  TREATMENT  OF  ACUTE  INFECTIOUS  DISEASES 

lost  but  little  of  its  efficacy  in  eliciting  antitoxin  formation  by  the  tissues 
and  as  very  much  more  toxin  could  be  used  in  the  combination  a  great 
deal  more  antitoxin  was  manufactured  by  the  body  in  a  much  briefer 
period.  The  injection  used  at  any  age  is  about  400  times  the  fatal  dose 
for  a  half-grown  guinea  pig  and  the  amount  of  antitoxin  required  to 
neutralize  it  is  about  4  units.  The  dose  is  1  c.c.  of  the  toxin-antitoxin 
so  prepared,  repeated  every  7  days  for  3  doses.  For  children  under 
one  year,  0.5  c.c.  at  weekly  intervals  for  3  doses.  The  method,  a 
subcutaneous  injection  into  any  convenient  site,  such  as  the  insertion 
of  the  deltoid. 

Reactions.  These  are  usually  less  marked  than  after  the  more  com- 
monly used  typhoid  vaccine  and  like  the  latter  consist  of  more  or  less 
redness  and  swelling  at  the  site  of  injection  with  or  without  a  constitu- 
tional reaction,  such  as  one  attributes  to  a  mild  infection.  It  lasts  one 
to  three  days. 

Infants  as  a  rule  have  neither  local  nor  constitutional  reactions. 
Older  children  and  adults  suffer  the  reaction  in  something  less  than 
one-third  of  the  cases. 

The  acquisition  and  duration  of  immunity.  Antitoxin  is  slow 
in  its  formation.  Rarely  is  the  amount  protective  in  less  than  three 
weeks  and  as  a  rule  not  until  the  second  month  and  in  some  cases  dallying 
along  even  to  the  sixth  month. 

Tested  three  months  after  the  injection  nearly  75  per  cent,  are  immune 
after  one  injection,  90  per  cent,  after  two  and  95  per  cent,  after  three. 
The  Department  of  Health  found  that  in  young  infants  harboring  their 
mothers'  antitoxin  the  immunizing  powers  were  not  as  complete,  giving 
50  per  cent,  immune  only  after  a  year  later. 

The  best  period  for  active  immunization  is  6  months  to  5  years. 

Antitoxin  once  started  by  this  method  seems  to  keep  on  forming 
and  90  per  cent,  of  a  small  number  (100)  observed  by  the  Department 
were  immune  after  4  years. 

Active  immunization  has  certainly  won  a  second  great  battle  in  our 
campaign  against  this  disease;  for  owing  to  certain  factors,  seemingly 
almost  impossible  to  overcome,  the  results  of  antitoxin  administration 
had  come  to  an  impasse  as  shown  by  the  unchanging  statistics  of  mor- 
tality in  diphtheria  for  a  number  of  years  past;  antitoxin  cut  the  mor- 
tality more  than  a  half,  from  about  28  per  cent,  to  a  little  under  12  per 
cent.,  but  the  neglect  of  families  to  call  medical  assistance  until  late 
in  the  first  week,  when  antitoxin  can  do  but  little,  or  even  delay  until 
the  patient  was  moribund  or  failure  to  recognize  the  disease  on  the  part 
of  the  physician  are  all  factors  contributing  to  mortality  that  it  seems 
impossible  to  correct  by  mere  words  of  warning. 


DIPHTHERIA  449 

It  is  easy  to  see  how  by  determining  susceptible  individuals  by  the 
Schick  reaction  applied  in  schools,  hospitals,  institutions,  in  communities 
the  seat  of  an  epidemic,  and  in  families  invaded,  the  definite  determina- 
tion of  susceptibility  brings  the  weapons  of  fear  and  moral  obligation  to 
enforce  active  immunization  to  prevent  spread.  It  will  be  seen  in  dis- 
cussing carriers  how  impossible  it  is  to  eliminate  these  from  a  community 
and  how  safety  can  be  found  only  in  a  community  rendered  immune  to 
diphtheria  by  active  immunization.  The  Schick  and  immunization  to 
diphtheria  should  be  as  compulsory  as  vaccination  against  small  pox  and 
the  results  would  probably  be  equally  efficacious. 

If  the  case  cannot  be  isolated  in  the  home  it  should  be  removed 
to  a  hospital,  if  one  is  accessible.  Treated  at  home  one  chooses  a 

Room.  The  choice,  preparation  and  maintenance  of  the  room 
in  a  case  of  diphtheria  is  the  same  as  in  a  case  of  scarlet  fever.  (See 
Scarlet  Fever,  Chap.  XVII.) 

Nurse.  Identical  instructions  should  be  given  and  precautions 
taken  as  in  a  case  of  scarlet  fever.  (See  Scarlet  Fever,  Chap.  XVII.) 

It  is  to  be  remembered,  however,  that  the  great  danger  comes  from 
the  secretions  of  the  throat  and  nose  and  every  precaution  must  be  taken 
in  the  treatment  of  the  throat  or  nose  to  avoid  receiving  a  cough  or  sneeze 
direct  in  the  face.  All  the  secretions  should  be  received  on  cloths  that 
may  be  burned. 

The  nurse  may  use  mild  sprays  and  gargles  as  a  precautionary  meas- 
ure, but  no  astringents.  It  is  to  be  remembered  that  the  healthy  mucous 
membrane  is  resistant  to  invasion  by  the  bacillus,  but  when  abraded, 
irritated  or  inflamed  becomes  the  site  of  infection. 

A  wise  measure  on  the  part  of  the  nurse  is  to  submit  to  a  Schick 
reaction  and  in  case  it  proves  positive  to  accept  an  immunizing  dose  of 
antitoxin,  1,000  units,  repeated  at  an  interval  of  three  weeks. 

A  nurse  liable  to  contact  with  diphtheria  should  receive  active  immu- 
nization if  the  Schick  reaction  indicates  it. 

The  bacillus  is  not  air  borne  and  the  antiseptic  bath  and  shampoo 
when  the  nurse  is  likely  to  meet  others  outside  the  house  is  not  so  im- 
perative as  in  the  case  of  scarlet  fever,  but  she  should  not  see  children  on 
these  occasions  nor  come  into  so  close  contact  with  others  that  she  might 
convey  bacilli  from  her  own  throat,  by  coughing,  sneezing,  close  conver- 
sation or  kissing. 

Physician.  Such  precautions  as  the  physician  takes  in  visiting 
a  scarlet  fever  case  he  takes  in  treating  diphtheria.  (See  Scarlet  Fever, 
Chap.  XVII.) 

He,  too,  remembers  that  his  danger  lies  in  examining  the  throat 
and  in  the  cough  he  provokes.  He  may  use  mild  gargles  or  sprays, 


450  TREATMENT  OF  ACUTE  INFECTIOUS  DISEASES 

one-half  strength  Dobell's  solution  or  saturated  solution  of  boric  acid; 
but  if  the  patient  has  coughed  in  his  face  he  should  certainly  have  re- 
course to  an  immunizing  dose  of  antitoxin,  1,000  units,  if  he  has  not 
already  done  so  as  a  matter  of  precaution^ 

The  physician  who  in  his  practice  is  likely  to  treat  diphtheria  should  by 
a  Schick  reaction  determine  his  susceptibility  and  in  case  of  a  positive 
reaction  fortify  himself  against  infection  by  active  immunization. 

With  the  knowledge  of  the  organism,  its  origin  and  mode  of  trans- 
mission, he  finds  the  antiseptic  bath  after  the  case  less  compelling  than 
in  scarlet  fever,  but  is  doubly  cautious  about  his  mouth  and  throat  and 
the  danger  of  conveying  infection  from  them,  as  he  may  well  do  in  his 
own  family. 

Precautions  in  the  Sick  Room  and  the  temperature  of  the  room 
are  the  same  as  those  observed  in  scarlet  fever.  (See  Scarlet  Fever, 
Chap.  XVII.) 

Bed.     (See  Chap.  IX.) 

Patient.  The  patient  must  be  made  to  go  to  bed,  no  matter 
how  light  the  attack  may  appear  to  be,  explanations  being  made  to  him, 
or  to  the  parents,  of  the  insidious  effects  of  the  disease  on  the  cardio- 
vascular apparatus  and  the  kidney  and  the  meaning  of  rest,  such  only 
as  the  bed  can  afford,  to  these  structures. 

Bath.  A  warm  sponge  bath  of  soap  and  water  is  given  each  day 
for  cleansing  purposes. 

Nightgown.  Such  an  one  as  can  be  easily  opened  for  examina- 
tion of  the  heart  and  lungs  without  effort  to  the  patient. 

To  the  parents  or  friends  the  physician  must  talk  frankly  of  the 
dangers  that  any  phjrsical  effort  on  the  part  of  the  patient  entails  in 
terms  of  cardiac  failure.  They  must  understand  that  this  danger  is 
greatest  as  convalescence  approaches.  It  is  the  only  way  in  which  the 
insistency  of  the  patient  and  especially  the  little  patient  can  be  met. 

The  rest,  even  in  the  mild  cases,  must  be  absolute;  the  patient  re- 
maining in  recumbency,  not  allowed  to  turn  himself  without  help,  if  the 
case  has  in  any  measure  been  severe  and,  indeed,  in  all  cases  the  bed-pan 
must  be  insisted  on. 

During  the  height  of  the  illness  only  one  low  pillow  should  be  allowed 
and  another  not  until  the  end  of  two  weeks  and  not  even  then  if  he  has 
been  very  ill  or  there  are  any  indications  of  nerve  involvements. 

Diet.  There  are  certain  fundamental  principles  that  determine 
the  dietary  in  all  acute  febrile  diseases.  An  occasional  review  of  these 
principles  is  extremely  helpful  in  doing  justice  to  a  field  of  therapy 
grossly  neglected.  (See  Diet  in  Acute  Febrile  Diseases,  Chap.  II.) 

Tissue  destruction  in  acute  infections  is  due  to  three  causes:  (1) 


DIPHTHERIA 


451 


pyrexia;  (2)  toxemia;  (3)  starvation.  In  diphtheria  the  first  factor 
is  feebly  operative,  for  as  a  rule  there  is  little  fever  and  in  many  of  the 
worst  cases  none  at  all;  but  the  second  factor,  the  operation  of  toxins  is 
perhaps  more  potent  than  in  any  of  the  common  infections,  while  the 
third  factor  is  enhanced  by  the  difficulty  of  swallowing  in  angina. 

Moreover,  it  has  been  shown  that  tissue  destruction  continues  well 
beyond  the  febrile  period,  as  if  a  late  autolysis  had  occurred  in  tissue 
attacked  by  the  toxin  earlier  in  the  infection.  This  tissue  destruction 
both  early  and  late  has  been  lessened  or  stayed  by  a  sufficiency  of  diet 
and  considering  the  important  organs  attacked  by  the  toxins,  heart, 
kidney,  nerve  tissue,  enough  food  to  meet  the  daily  metabolic  demands 
and  furnish  material  for  repair  is  in  this  disease  especially  urgent. 

The  details  of  such  a  dietary  are  to  be  found  under  Diet  in  scarlet 
fever  (see  Scarlet  Fever,  Chap.  XVII),  and  needs  no  modification  for 
diphtheria. 

In  diphtheria,  however,  both  the  angina  and  pharyngeal  paralysis 
may  make  the  feeding  exceedingly  difficult.  If  from  pain,  regurgitation 
through  the  nose  and  disinclination,  the  diminution  of  food  intake 
threatens  the  strength,  the  food  must  be  administered  by  gavage  or  by 
rectum.  The  stomach  tube  is  the  best  means  to  effect  this  end.  In  the 
adult  one  may  feed  by  the  tube,  milk  500  c.c.,  sugar  50  grams,  and  one 
egg  three  times  a  day,  or  one  may  fortify  this  food  by  adding  milk  sugar 
1  to  2  ounces  and  cream  1  to  2  ounces  or  even  more,  at  each  feeding.  In 
this  way  one  may  get  in  well  over  2,000  calories. 

In  young  infants  the  stomach  tube  is  preferable,  but  over  the  age 
of  three  years  more  difficult  than  the  use  of  a  nasal  tube. 

Rectal  feeding  is  not  so  satisfactory,  but  when  the  feeding  by  the 
mouth  is  difficult  or  impossible  may  answer  in  some  measure  for  a  brief 
period. 

When  swallowing  is  painful  an  insufficiency  of  water  is  ingested  and 
a  pint  of  water  twice  a  day  by  the  rectum  or  a  Murphy  drip  may  supply 
the  needy  tissues. 

A  nursing  infant  affected  should  be  taken  from  the  breast  but  fed 
the  mother's  milk  obtained  by  the  use  of  a  pump  or  by  expression  and  if 
this  is  insufficient,  the  milk  of  a  wet  nurse  can  be  used  to  advantage. 
Mixed  feeding  may  be  cautiously  undertaken,  but  it  is  a  bad  time  to 
institute  artificial  feeding  of  any  kind. 

Water  or  diluted  fruit  juices  should  be  given  as  freely  as  the  patient 
wishes  and,  indeed,  should  be  offered  every  hour  or  two,  as  apathy 
induces  on  the  part  of  the  patient  neglect. ' 

Mouth,  Throat  and  Nose.  The  toilet  of  the  mouth,  throat  and 
nose  is  important.  It  is  rather  prophylactic  than  curative.  When 


452  TREATMENT  OF  ACUTE  INFECTIOUS  DISEASES 

properly  carried  out,  it  lessens  the  probability  of  mixed  infections  and 
extensions. 

Whatever  is  done  must  be  done  with  care  and  gentleness;  for  any 
trauma  suffered  by  the  invaded  tissues,  enhances  the  spread  and  severity 
of  the  diphtheritic  process  and  invites  the  invasion  by  other  organisms. 

The  purpose  is  cleanliness  and  nothing  subserves  this  .purpose  better 
than  physiological  salt  solution,  as  spray,  or  irrigation.  DobelFs  solution 
in  one-half  or  one-quarter  strength  may  be  used  for  the  same  purpose. 

After  taking  food  the  mouth  should  be  rinsed  with  one  or  the  other 
of  these  solutions  and  the  teeth,  the  spaces  between  the  teeth  and  the 
dead  spaces  in  the  mouth,  cleansed  of  particles  of  food  by  cotton  on  a 
tooth-pick  as  an  applicator  soaked  in  these  solutions. 

When  there  is  sordes,  the  milder  applications  may  well  be  preceded  by 
half  strength  hydrogen  peroxide.  The  softened  coat  on  the  tongue  may 
be  removed  in  part  by  scraping  with  the  edge  of  a  whalebone. 

A  dry  mouth  is  relieved  by  equal  parts  of  2  per  cent,  boric  acid  solu- 
tion and  albolene  (liquid  petrolatum)  to  which  a  little  lemon  juice  has 
been  added;  if  there  is  fetor  or  a  foul  stomatitis  the  following  prescription 
is  useful: 

S 

Phenol  (watery  solution  1  in  20) 

Glycerin aa  5i  30 

Boric  Acid  (saturated  watery  sol.) 5  viii       240 

M. 

Follow  this  with  the  milder  applications. 

For  the  nose  use  the  same  mild  solutions  with  the  applicator  or  spray, 
but  avoid  the  douche.  For  dried  secretions,  use  a  little  olive  oil  on  an 
applicator  to  soften  before  using  the  saline  or  DobelFs. 

The  genitals  are  freed  from  secretions  by  the  use  of  the  same  so- 
lutions. 

With  angina  or  nasal  involvement  the  above  procedures  are  modified 
or  supplemented. 

Bowels.  Putrefactive  processes  in  the  large  intestine,  enhanced 
by  constipation  and  possibly  by  other  conditions  attendant  upon  infec- 
tion will  only  add  to  the  burden  the  patient  has  to  carry;  hence,  attention 
to  the  bowel  early  in  the  illness  is  of  importance. 

Calomel  and  salts  may  be  given  to  the  production  of  one  or  two  loose 
movements. 

Calomel  in  gr.  1/4  (0.015  Gm.)  doses  every  15  minutes  until  1  or  1  1/4 
grains  (0.060-0.075  Gm.)  are  taken  work  well  in  the  child  and  may  be 
followed  in  2  or  3  hours  by  a  half  ounce  of  milk  of  magnesia. 

In  young  children  or  adults,  salts,  Epsom  or  Rochelle,  in  doses  of 


i 


DIPHTHERIA  453 

5ss.  to  i  (15-30  Gm.)  in  a  half  to  three-quarter  glass  of  water  are  effica- 
cious or  we  may  give  1  1/2  to  2  grains  (0.10-0.120  Gm.)  of  calomel  and 
follow  in  about  3  or  4  hours  by  the  above  dose  of  salts. 

The  bowels  should  be  kept  open  either  by  the  use  of  an  enema  or  a 
mild  saline  water  of  the  type  of  Hunyadi  or  Liq.  Magnesii  Citratis  given 
every  other  day. 

Serum  Treatment.  The  success  of  modern  medicine  is  the  re- 
ward of  an  effort  to  discover  Nature's  method  of  combating  disease. 
Nowhere  has  that  success  been  more  unqualified  than  in  the*  field  of 
serum  therapy  in  its  application  to  diphtheria. 

The  bacillus  diphtherise  is  one  of  the  relatively  few  organisms  which 
secretes  its  poison  to  operate  at  a  distance  from  the  site  of  its  growth 
and  multiplication.  This  deleterious  material  is  called  a  toxin.  Many 
more  pathogenic  organisms  exert  their  toxic  effect  upon  the  host  by  a 
material  so  closely  associated  with  their  substance  that  its  liberation 
depends  on  the  destruction  or  damage  of  their  own  structure.  These 
toxins  are  called  endo-toxins.  We  do  not  know  the  chemical  nature  or 
intimate  structure  of  the  toxins,  but  we  know  something  of  their  effects 
and  none  are  more  remarkable  than  their  effect  to  excite  in  the  tissues  of 
the  animal  invaded  the  production  of  substances  that  neutralize  their 
toxic  action,  that  is,  antitoxins. 

Invading  the  tissues  of  the  upper  air-passages,  the  diphtheria  bacillus 
finds  a  suitable  soil  for  multiplication.  Here  it  secretes  its  toxin,  which 
operating  locally  causes  inflammation  with  destruction  of  tissue,  which 
produces  the  characteristic  membrane  and  passing  into  the  circulation 
attacks  various  tissues,  for  some  of  which  it  has  an  especial  affinity  and 
upon  which  it  exerts  its  toxic  effects  peculiarly;  such  are  nervous  tissue 
and  those  of  the  heart  and  kidney. 

These  toxic  molecules  are  believed  to  consist  of  a  nucleus  with  certain 
chemical  groups,  assumed  to  be  akin  to  the  side  chains  of  a  benzol  ring. 
One  of  these  side  chains  has  an  affinity  for  certain  side  chains  in  the 
molecules  composing  the  tissues  concerned  and  effect  through  these  an 
attachment  of  the  toxin  to  the  cell.  This  side  chain,  seizing  the  cell,  as  it 
does,  is  called  a  haptophore  group.  The  toxin,  too,  has  another  side 
chain,  which  thus  brought  into  intimate  contact  with  the  cell  exerts  an 
injurious  effect  upon  it.  This  is  the  toxophore,  or  poison  bearing  group. 
The  damage  done  the  cell  by  this  toxophore  group,  if  it  does  not  kill  it, 
stimulates  it  to  reparative  processes.  The  part  repaired  is  the  group 
damaged,  that  is,  the  haptophore  group  of  the  cell,  seized  by  the  hapto- 
phore group  of  the  toxin.  This  process  of  repair  is,  however,  in  excess  of 
actual  need  and  the  superfluity  of  haptophore  groups  of  the  cell  are  set 
free  from  it  into  the  blood  stream  and,  combining  with  the  toxins  not  yet 


454  TREATMENT  OF  ACUTE  INFECTIOUS  DISEASES 

attached,  divert  them  from  the  cells.  This  substance,  that  is,  these 
haptophores  of  the  cells,  are  called  antitoxin. 

When  the  antitoxin  has  been  manufactured  in  sufficient  abundance  to 
neutralize  successfully  the  toxin,  the  animal  is  said  to  have  acquired  an 
immunity  and  this  process  is  one  of  active  immunization,  active  because 
the  tissues  have  been  physiologically  active  in  the  production  of  their 
own  mechanism  of  defense. 

But  if  the  blood  of  the  animal,  so  cured,  or  the  blood  of  an  animal 
in  whom  the  same  process  had  been  induced  by  introducing  the  toxin 
gradually,  that  is,  giving  him  the  disease  by  degrees  and  repeatedly 
inducing  ever  increasing  degrees  of  immunity,  is  drawn  off  and  this 
antitoxic  substance  be  isolated,  it  can  in  turn  be  injected  into  another 
animal  and  neutralize  toxins  circulating  in  his  blood  or  tissue  fluids 
and  render  him  immune;  but  as  this  latter  animal's  tissues  have  not  been 
actively  engaged  in  the  manufacture  of  this  antitoxin  injected,  he  is  said 
to  have  a  passive  immunity  conferred  on  him. 

Diphtheria  antitoxin,  then,  is  manufactured  by  the  horse  in  the 
process  of  acquiring  an  active  immunity  to  the  diphtheria  toxins  in- 
jected into  the  tissues  in  increasing  doses.  This  is  withdrawn,  sub- 
mitted to  certain  processes  for  isolation  and  preservation  and  used  in  the 
treatment  of  diphtheria  in  man,  on  whom  its  injection  bestows  a  passive 
immunity. 

Methods  of  preparation  have  improved  since  first  this  agent  was 
offered  to  therapy  and  appreciation  of  its  close  relation  to  certain  glob- 
ulins in  the  serum  has  made  it  possible,  by  isolating  these,  to  avoid  in 
some  measure  certain  disagreeable  results  attendant  on  its  usage  and  has 
at  the  same  time  procured  a  more  concentrated  product. 

Some  measure  of  its  activity  had  of  course  to  be  sought,  and  the 
unit  that  has  been  established  is  in  terms  of  its  power  to  neutralize 
toxic  doses  in  definite  animals  of  definite  weights. 

The  unit  agreed  upon  is  the  amount  of  antitoxin  which  will  just 
neutralize  100  minimal  fatal  doses  of  toxin  for  a  250-gram  guinea-pig. 

Antitoxin  coming  from  reliable  sources  is  fairly  stable,  if  properly 
preserved.  According  to  Park  if  kept  cold  and  not  exposed  to  light  and 
air,  it  will  not  deteriorate  more  than  30  per  cent,  in  a  year.  It  loses  some 
10  per  cent,  in  two  months.  Allowance  may  be  made  for  this  in  dosage. 

Dose.  We  cannot  estimate  the  amount  of  toxin  in  a  given  case 
and  so  cannot  use  it  as  a  measure  of  the  quantity  of  antitoxin  to  be 
used.  Our  dose  is  established  empirically  largely. 

The  dose  is  not  determined  by  age,  except  in  very  young  children, 
under  two  years,  when  it  is  slightly  less. 

Park  and  Biggs  think  weight  should  have  some  consideration. 


DIPHTHERIA  455 

No  amount  is  known  to  be  injurious  in  any  measure.    The  limit  of 
the  dose  is  set  by  the  needs  of  the  case  and  by  expense. 
The  dose  is  modified  by  two  considerations : 

1.  The  severity  of  the  disease. 

2.  The  day  of  the  disease  when  first  seen. 

The  tendency  in  this  country  is  to  be  liberal  in  the  dosage.  It  is 
a  good  rule  when  in  doubt  whether  to  give  a  larger  or  smaller  dose  to 
choose  the  larger. 

When  Seen  Early.  In  mild  cases,  that  is,  in  cases  of  simple  con- 
gestion from  which  the  bacillus  has  been  recovered,  or  in  those  with 
a  small  patch  confined  to  one  tonsil,  give  3,000  to  5,000  units. 

This  should  be  repeated  in  twelve  hours  if  there  is  no  sign  of  improve- 
ment. If  better,  one  may  wait  for  twelve  hours  longer,  repeating  the 
dose  if  improvement  does  not  continue. 

A  More  Severe  Case,  such  as  involves  both  tonsils,  requires  a 
larger  dose  5,000  to  6,000  units  and  should  be  seen  again  in  six  hours. 
If  spreading,  repeat;  if  not,  wait  another  six  hours.  If  no  signs  of  im- 
proving, give  the  second  dose  and  repeat  at  six  or  twelve  hour  intervals 
until  the  improvement  is  satisfactory. 

If  the  process  has  spread  from  the  tonsils  onto  the  pillars  or 
pharynx  give  8,000  units  and  repeat  at  six  to  twelve  hour  intervals  as 
above. 

If  a  pharyngeal  case  shows  (1)  decided  toxic  symptoms  or  (2),  if 
there  are  any  laryngeal  manifestations,  such  as  hoarse  cry,  stridor  or 
laryngeal  cough  or  (3),  if  in  addition  to  pharyngeal  involvement  there 
is  nasal  involvement  give  10,000  units. 

In  these  cases  and  especially  in  the  laryngeal,  the  case  should  be 
continuously  watched,  both  to  be  prompt  in  repeating  the  dose  and  to 
intervene  with  the  intubating  tube,  if  needed. 

The  dose  should  be  repeated  every  six  hours  until  there  is  improve- 
ment and  if  the  spread  is  increasing  one  may  repeat  in  four  hours. 

In  malignant  cases,  cases  in  which  the  spread  is  very  rapid  and  the 
symptoms  toxic  15,000  to  20,000  units  should  be  given. 

If  the  dose  can  be  given  intravenously  the  result  will  be  best.  If  the 
vein  cannot  be  entered,  as  is  the  case  often  in  small  children,  go  into  the 
muscles  of  the  buttock,  as  the  wide  net-work  of  veins  in  the  muscle  facili- 
tates absorption. 

These  doses  are  repeated  at  four,  six  or  twelve  hour  intervals  and 
are  sometimes  carried  to  total  amounts  of  60,000  to  100,000  units. 
Apparently  hopeless  cases  sometimes  rally  under  this  large  dosage.  Both 
McCollom  of  Boston  and  Weaver  of  Chicago  are  advocates  of  these 
large  doses. 


456  TREATMENT  OF  ACUTE  INFECTIOUS  DISEASES 

In  severe  or  laryngeal  cases  under  two  years  the  dose  is  5,000  to 
6,000  units,  repeated  at  six,  eight  or  twelve  hour  intervals. 

Cases  Seen  Late.  Every  day  of  delay  increases  the  dangers,  both 
in  terms  of  death  and  complications,  heart,  kidney  or  nerve  involve- 
ments. 

When  antitoxin  is  administered  on  the  first  day  the  results  are  most 
brilliant,  the  mortality  amounting  to  only  a  little  over  1  per  cent,  and 
in  some  considerable  series  with  no  mortality. 

But  on  the  second  day  the  dangers  have  increased  and  the  statistics 
show  about  4  per  cent,  to  5  per  cent,  and  in  some  series  a  still  higher. 

The  mortality  of  cases  treated  on  the  third  day  has  doubled  and  tripled 
over  the  second,  running  from  9  per  cent,  to  13  per  cent,  and  on  the 
next  day  still  higher,  15  per  cent.,  17  per  cent.,  even  24  per  cent,  in  some 
series. 

This  means  larger  doses  with  each  day.  Holt  has  said  if  the  case 
has  been  three  days  ill  he  should  have  three  times  the  ordinary  dose. 

The  tendency,  I  think,  is  toward  liberal  dosage.  Park  has  pointed 
out  that  the  "larger  the  amount  injected  into  the  tissues  the  quicker 
will  a  considerable  amount  be  absorbed  into  the  blood  and  pass  into  the 
body  fluids.  Only  a  small  percentage  of  what  is  in  the  blood  passes  out 
of  the  vessels  into  the  tissue  fluids.  It  is  for  this  reason  that,  if  we 
would  neutralize  toxin  that  has  passed  from  the  blood  stream,  but  has 
not  yet  united  with  the  tissue  cells,  very  much  more  must  be  given  than 
the  amount  of  antitoxin  that  would  be  required  in  a  test-tube  to  neu- 
tralize the  toxin." 

Moreover  it  has  been  shown  that  the  toxin  is  not  a  simple  body, 
but  that  a  certain  portion,  called  protoxoid  has  to  be  neutralized  before 
the  toxin  is  affected  and  neutralized  and  that  then  there  is  a  portion, 
called  toxon,  which  is  believed  to  be  responsible  for  the  toxic  changes  in 
nerve  tissue  which  does  not  combine  with  antitoxin  until  all  the  toxin 
molecules  are  satisfied.  It  is  necessary,  then,  to  give  such  large  doses 
as  may  reasonably  assure  us  that  this  portion,  the  toxon,  shall  be  neu- 
tralized. It  must  be  remembered  that  the  body  is  at  the  same  time 
manufacturing  its  own  antitoxin  which  may  have  increased  the  richness 
of  antitoxin  content  of  the  blood  enormously. 

The  following  is  the  dosage  advised  by  the  Board  of  Health  of  the 
City  of  New  York  and  quoted  from  its  circular  sent  with  its  diphtheria 
antitoxin : 


DIPHTHERIA 


457 


AMOUNT  OF  ANTITOXIN  REQUIRED  IN  THE  TREATMENT  OF  A  CASE 


Mild  Cases 

Moderate 

*  Severe 

*  Malignant 

Infants,  10  to  30  Ibs.  in  weight 
(under  2  years  of  age)    

(  2,000  units 
to 
[  3,000  units 

3,000  units 
to 
5,000  units 

5,000  units 
to 
10,000  units 

7,500  units 
to 
10,000  units 

Children,  30  to  90  Ibs.  in  weight 
(under  15  years  of  age)  

3,000  units 
to 
4,000  units 

4,000  units 
to 
10,000  units 

10,000  units 
to 
15,000  units 

10,000  units 
to 
20,000  units 

Adults,  90  Ibs.  and  over  in  weight 

(3,000  units 
to 
5,000  units 

5,000  units 
to 
10,000  units 

10,000  units 
to 
20,000  units 

20,000  units 
to 
40,000  units 

*  When  given  intravenously  one-half  the  amounts  stated. 

Cases  of  laryngeal  diphtheria,  moderate  cases  seen  late  at  the  time  of 
the  first  injection,  and  cases  of  diphtheria  occurring  as  a  complication 
of  the  exanthemata  should  be  classified  and  treated  as  " severe"  cases. 
It  is  recommended  that  the  methods  of  administration  be  as  follows: 
Mild  Cases — Subcutaneous  or  intramuscular. 
Moderate  Cases — Intramuscular  or  subcutaneous. 
Severe  Cases — Intramuscular  or  J^  intravenous  and  }/%  intra- 
muscular or  subcutaneous. 
Malignant  Cases — Intravenous  or  intramuscular. 

Some  point  on  the  surface  of  the  body  should  be  chosen  for  the  in- 
jection, as  where  there  is  an  abundance  of  subcutaneous  cellular  tissue, 
the  abdomen  or  intrascapular  region.  Before  the  remedy  is  administered, 
the  skin  should  be  sterilized  at  the  point  of  injection  with  tincture  of 
iodine  or  other  disinfectant.  The  syringe  should  be  thoroughly  sterilized, 
It  is  better  not  to  employ  massage  over  the  point  of  injection. 

THE  EARLY  ADMINISTRATION  OF  ANTITOXIN 

The  earlier  the  remedy  is  administered  the  more  certain  and  rapid  is  the 
effect.  In  cases  of  any  severity  where  diphtheria  is  suspected,  and  in 
cases  of  croup,  it  is  far  better  to  administer  the  remedy  at  once,  making 
a  culture  at  the  same  time,  than  to  delay  the  treatment  until  a  diagnosis 
has  been  made  by  bacteriologic  examination.  The  first  injection  should 
be  large  enough  to  control  the  disease.  One  large  dose  given  early  is  far 
more  efficacious  than  the  same  amount  in  divided  doses.  Severe  cases 
and  those  in  which  the  administration  of  antitoxin  has  been  delayed,  or 
cases  which  are  progressive  because  of  an  insufficient  first  dose,  should 
be  given  a  large  intravenous  injection  whenever  feasible.  In  this  way 
the  full  value  of  antitoxin  is  obtained  at  once,  whereas  the  absorption  from 


458  TREATMENT  OF  ACUTE  INFECTIOUS  DISEASES 

the  subcutaneous  injection  is  so  slow  that  many  hours  must  elapse  before 
any  great  amount  of  antitoxin  has  found  its  way  into  the  general  circula- 
tion. It  must  be  warmed  to  the  body  temperature  and  given  very 
gradually. 

Technique.  The  operator's  hands  should  be  cleansed  with  soap 
and  water  and  alcohol  or  1  to  1000  bichloride. 

The  skin  of  the  patient  should  be  cleansed  with  soap  and  water  and 
alcohol,  or  a  good  scrubbing  with  alcohol  may  answer,  or  the  skin  painted 
with  the  tincture  of  iodine. 

Antitoxin  is  now  put  up  by  a  number  of  reliable  firms,  sent  in  con- 
tainers which  are  themselves  the  syringes,  with  sterile  needles  accom- 
panying. This  needle  may  be  dropped  into  alcohol  before  using,  as  an 
extra  precaution.  If  such  conveniences  are  not  at  hand,  a  glass  syringe 
or  one  that,  like  it,  may  be  subjected  to  boiling  should  be  used. 

The  needle  should  be  boiled  and  attached  by  a  short  piece  of  sterile 
rubber  tubing  to  the  syringe.  This  is  intercalated  to  prevent  breaking 
or  bending  or  wounding  other  structures  if  the  child  struggles. 

A  syringe  from  which  the  plunger  may  be  withdrawn  is  preferable 
because  the  serum  may  more  readily  be  poured  into  the  barrel  of  the 
syringe  than  drawn  up  through  the  needle.  When  this  is  done  the  little 
air  must  be  expelled  through  the  needle  before  it  is  used. 

Site.  An  excellent  one  is  the  loose  tissue  of  the  back  at  the  angle 
of  the  scapula,  into  the  loose  tissue  of  the  abdominal  wall  or  into  the 
buttock  or  in  the  nipple  line  between  the  nipple  and  costal  margin.  This 
last  is  a  site  upon  which  the  patient  rarely  lies  and  if  a  local  reaction 
occurs,  local  applications  are  readily  made,  and  if  it  is  desired  to  give  it 
into  the  muscle  in  an  urgent  case  the  buttock  serves  well.  I  prefer  the 
side  of  the  buttock. 

As  has  been  said,  in  profoundly  toxic  cases  an  intravenous  injection 
is  to  be  preferred,  if  possible. 

(For  technique  of  intravenous  injection  see  Pneumonia,  Chap.  IX.) 

Evidences  of  Improvement.  First,  a  pause  in  the  spread  of 
the  membrane;  then,  in  twelve  hours  to  twenty-four  hours  the  mem- 
brane softens,  loosens,  recedes,  disintegrates.  With  this  the  swelling 
of  the  mucous  membranes  diminishes  and  there  is  an  amelioration  of 
the  general  condition,  a  betterment  of  the  pulse,  and  a  lowering  of  the 
temperature. 

In  laryngeal  cases,  the  stridor  lessens,  there  is  an  improvement  in  the 
cry  or  voice  and  the  cough  is  looser.  In  nasal  cases  the  breathing  is  less 
obstructed  and  the  discharge  lessened. 

Disagreeable  or  dangerous  results  of  antitoxin  administration. 
Skin  rashes  are  by  far  the  most  common,  but  far  less  frequent  with 


DIPHTHERIA  459 

the  use  of  the  refined  and  concentrated  serum  than  with  the  old.  An 
erythema  may  be  seen  in  a  few  hours,  but  it  soon  disappears.  After 
a  period  of  days,  seven  to  fourteen,  a  rash  occurs,  either  erythematous, 
that  may  be  mistaken  for  scarlet  fever  (the  mucous  membranes  of 
the  mouth  and  pharynx  are  not  affected,  a  distinguishing  feature  from 
scarlet  fever)  and  which  may  desquamate;  morbiliform,  mistaken  for 
measles,  or  most  commonly,  urticarial,  which  may  give  much  annoyance. 

This  eruption  is  often  accompanied  by  other  manifestations  of  intoxi- 
cation; a  little  temperature,  swelling  of  the  glands  and  at  times  enough 
joint  pains  to  suggest  rheumatism  and  perhaps  a  little  albuminuria.  The 
whole  process  and  the  period  intervening  between  it  and  the  injection 
suggest  a  period  of  incubation  of  an  infectious  disease  and  is  attributed  to 
the  effects  of  certain  proteins  in  the  serum  and  their  effects  on  the  tissues 
to  the  production  of  toxic  substances.  It  occurs  commonly  after  the  first 
injection  and  is  not  to  be  confounded  with  that  more  sudden  and  explo- 
sive reaction  that  may  follow  an  injection  repeated  ten  days  or  longer 
after  the  first  injection,  the  result  of  a  sensitization  of  the  tissues  by  the 
first  serum  introduced,  constituting  the  phenomenon  known  as  anaphy- 
laxis. 

The  most  important  part  of  the  treatment  of  this  condition  is  an 
explanation  of  its  meaning  to  the  parents  or  patient  who  may  be  alarmed 
by  its  manifestations. 

The  pains  may  be  allayed  by  fomentations  applied  to  the  joints 
or  by  the  use  of  acetyl  salicylic  acid  (aspirin).  The  urticaria  is  best 
treated  by  sponges  of  water  containing  sodium  bicarbonate  or  bran. 
Often  adrenalin  (epinephrin)  1:1000  in  doses  of  five  to  fifteen  minims 
affords  marked  relief.  It  lasts  but  two  or  three  days. 

Sudden  Deaths.  Very  rarely  sudden  deaths  or  a  condition 
threatening  death  occurs.  It  is  possible  that  some  of  these  sudden 
deaths  may  be  attributed  to  status  lymphaticus;  but  more  commonly 
they  have  occurred  in  people  who  are  asthmatics  and  of  these  a  con- 
siderable number  are  of  that  type  of  asthmatics  whose  attacks  are 
excited  by  the  presence  of  horses.  These  people  seem  to  be  sensitized 
to  some  protein  of  the  horse  given  off  in  the  secretions  or  discharges 
of  the  animal  which  are  carried  a  considerable  distance  through  the 
air. 

Injection  of  antitoxin  into  these  people  introduces  directly  the  sub- 
stance to  which  they  are  sensitized  and  an  anaphylactic  seizure  is  the 
result. 

I  saw  one  attack  in  a  physician,  a  victim  of  horse  asthma,  precipitated 
by  an  immunizing  dose  of  antitoxin  given  by  himself.  The  attack  was 
characteristic  of  its  kind  and  copied  the  reaction  in  the  animal  exactly. 


460  TREATMENT  OF  ACUTE  INFECTIOUS  DISEASES 

The  reaction  was  immediate,  before  the  needle  was  withdrawn.  He  was 
seized  with  most  urgent  dyspnoea,  intense  cyanosis  and  prostration.  His 
lungs  were  filled  to  the  utmost  and  he  was  incapable  of  expelling  air  from 
his  chest.  He  was  relieved  only  by  having  his  chest  encircled  by  the 
arms  of  his  attendant  and  compressed  until  air  was  expelled  that  might 
be  replaced. 

So  great  was  this  distension  that  acute  emphysema  ensued  with 
rupture  of  the  air  into  the  mediastinum  and  fascial  planes  of  the  neck. 
Atropine  and  morphine  and  adrenalin  were  liberally  administered. 
Cupping  also  afforded  some  relief. 

Asthmatics  should  receive  the  antitoxin  with  great  precaution. 

For  the  determination  of  sensitization  and  the  method  of  disensitiza- 
tion  see  Pneumonia  (Chap.  IX). 

In  sensitized  patients  Park  recommends  a  concentrated  antitoxin, 
calling  attention  to  the  fact  that  antitoxin  can  now  be  procured  with 
the  value  of  3000  units  to  1  c.c.  Give  of  this  0.2  c.c.  If  no  bad  results 
ensue  give  in  an  hour  another  0.2  c.c.  and  in  another  hour  0.4  c.c.  and 
repeat  this  amount  at  hourly  intervals  until  the  desired  dose  is  attained. 

Immunizing  Dose.  The  immunizing  dose  touched  upon  should 
be  500  units  in  infants  and  1000  in  older  children  and  adults. 

The  effect  lasts  but  a  short  time.  Park  says  that  at  the  end  of  five 
days  90  per  cent,  has  been  eliminated  and  at  the  end  of  two  weeks  99 
per  cent.  Hence,  in  the  presence  of  continued  danger  a  second  dose 
should  be  given  at  the  end  of  a  week  and  certainly  at  the  end  of  two. 

Park  also  advises  the  use  of  human  serum,  which  can  be  obtained 
containing  50  units  to  1  c.c.  for  immunizing  asthmatics. 

Laryngeal  Diphtheria.  The  gravity  of  this  condition  and  its 
frequency,  for  it  is  said  to  occur  in  40  per  cent,  of  children  attacked 
under  three  years,  make  it  imperative  to  appreciate  its  earliest  mani- 
festation. 

While  it  is  true  that  a  catarrhal  laryngitis  may  occur  in  pharyngeal 
diphtheria,  such  an  assumption  should  not  modify  our  procedure  in 
the  least. 

When  any  laryngeal  symptoms  occur  in  the  course  of  a  pharyngeal 
diphtheria,  it  is  to  be  treated  as  such  and  treated  promptly.  When, 
however,  the  laryngeal  diphtheria  is  primary,  the  differentiation  from 
catarrhal  laryngitis  and  spasmodic  croup  is  not  so  easy.  If  the  child 
has  been  exposed,  the  assumption  should  be  that  the  case  is  diphtheritic 
and  one  should  not  wait  upon  the  return  from  the  culture.  When  there 
has  been  no  exposure,  however,  one  has  to  obtain  a  culture  and  study 
the  course  of  the  disease. 

A  positive  culture,  of  course,  settles  the  matter,  but  a  negative  culture 


DIPHTHERIA  461 

does  not  exclude  it,  as  some  40  per  cent,  of  the  cases  coming  to  operation 
and  studied  by  McCollom  were  negative. 

Spasmodic  croup  is  usually  at  its  worst  at  night  and  with  the  morning 
finds  a  decided  amelioration  or  cessation  of  the  spasm,  but  when  the 
spasm  continues  into  the  succeeding  day  or  dyspnoea  comes  on,  that  is, 
the  lesion  shows  progression,  the  condition  should  be  assumed  to  be 
diphtheritic,  on  the  symptoms  alone. 

The  symptoms  are.  in  the  beginning,  hoarseness  of  the  voice  and  cough, 
which  takes  on  a  metallic  character.  This  is  in  the  catarrhal  or  earliest 
stage.  Soon  true  croup  begins,  characterized  by  spasm  of  the  larynx 
with  stridor  and  dyspnoea  but  with  remissions.  It  is  due  to  the  same 
irritative  causes  as  spasmodic  croup.  This  is  the  second  stage.  Follow- 
ing this  comes  the  evidences  of  continuously  increasing  obstruction  with 
dyspnoea,  cyanosis,  restlessness,  prostration,  feeble  pulse,  a  rising  tem- 
perature and  stupor.  No  such  clear  cut  stages  are  to  be  anticipated, 
however,  in  each  case. 

The  stridor  is  of  a  peculiar,  hissing  or  sawing  character  which  con- 
tinues throughout  inspiration  and  expiration. 

The  important  symptoms  are  hoarseness,  metallic  or  croupy  cough, 
restlessness,  prostration,  increasing  dyspnoea  taking  on  a  sawing  char- 
acter. 

McCollom  adds  one  other  symptom  upon  which  he  lays  great  diag- 
nostic stress,  namely,  a  rigidity  of  the  sterno-cleido-mastoid  muscles, 
which  he  says  is  always  present  and  even  early,  both  in  adult  and  chil- 
dren. 

Antitoxin  should  be  given,  as  noted  above,  at  the  earliest  moment 
and  in  large  doses,  10,000  units  and  repeated  in  six  hour  intervals,  if  there 
is  spread  and  in  six  or  twelve  hour  intervals  until  decided  improve- 
ment is  seen. 

Intravenous  administration  is  always  to  be  preferred. 

In  young  children  the  condition  may  prove  fatal  in  thirty-six  to  forty- 
eight  hours.  One  sees,  then,  how  urgent  the  early  administration  is. 

Before  antitoxin  treatment  90  per  cent,  of  these  cases  came  to  opera- 
tion; since  the  introduction  of  the  serum,  40  per  cent. 

Other  Treatment.  Besides  antitoxin  nothing  has  more  than  a 
palliative  effect  and  one  should  not  allow  any  measure  undertaken 
to  delay  the  administration  of  antitoxin  an  instant. 

Steam.  Inhalation  of  steam  seems  to  relieve  the  spasm  to  some 
extent,  though  of  course  not  the  obstruction. 

The  best  way  to  administer  it  is  with  the  croup  kettle  or  two  or  three 
croup  kettles  directing  their  steam  as  close  to  the  child's  head  as  is  safe. 
A  tent  may  be  made  by  putting  a  sheet  over  the  upper  third  of  the  bed,  so 


462  TREATMENT  OF  ACUTE  INFECTIOUS  DISEASES 

that  the  body  will  not  be  bathed  in  the  steam  or  one  may  lash  an  open 
umbrella  to  the  head  of  the  bed  and  pass  a  sheet  over  this  or  put  a 
clothes-horse  around  the  head  of  the  bed  and  drape  a  sheet  over  this. 
This  should  not  be  kept  up  for  long  periods,  as  the  heat  is  depressing. 

The  steam  lessens  the  spasms  and  is  said  to  facilitate  the  discharge 
of  secretions. 

Hot  fomentations  to  the  throat  have  been  advised  and  some 
authors  say  relief  is  sometimes  afforded  by  the  ice-bag  applied  to  the 
neck. 

INTUBATION 
BY  MINER  C.  HILL,  M.  D. 

Procedure.  1.  Select  intubation  tube  of  suitable  size  for  age  of 
child,  according  to  scale,  and  be  sure  that  braided  silk  thread  is  attached. 

2.  When  tube  is  on  the  obturator  the  broad  flange  of  the  head  should 
point  away  from  the  instrument.    The  silk  thread  is  then  to  the  opera- 
tor's right. 

3.  Assistant  wraps  child  in  a  mummy  sheet  and  places  some  padding 
under  the  neck  or  holds  the  patient's  head  over  edge  of  table.    Mouth 
gag  is  inserted  in  left  side  of  mouth. 

4.  Operator  takes  his  position  on  right  side  of  patient,  inserts  left 
index  finger  along  tongue,  parallel  with  median  line,  until  tip  of  finger 
locates  epiglottis  pulling  it  forward. 

5.  Handle  of  intubator  is  held  in  right  hand  close  to  the  patient's 
chest  with  one  finger  through  loop  of  thread  and  thumb  upon  the  re- 
leasing knob.  nfau 

6.  The  tube  is  then  advanced  along  midline  of  tongue  parallel  to 
left  index  finger  until  epiglottis  is  reached. 

7.  As  the  tube  engages  the  larynx  the  handle  of  intubator  is  raised 
and  the  tube  is  quickly,  but  without  force,  inserted  into  the  larynx. 
Any  undue  force  is  liable  to  cause  a  false  passage. 

8.  Tip  of  left  index  finger  holds  tube  in  place  while  releasing  knob  is 
pushed  forward  and  obturator  is  withdrawn. 

9.  When  tube  is  felt  securely  in  place  tip  of  left  index  finger  is  again 
placed  upon  head  of  tube  while  loop  of  silk  is  cut  and  withdrawn. 

10.  A  tracheotomy  set  should  always  be  in  readiness  in  case  intu- 
bation is  unsuccessful. 

A  successful  intubation  is  made  evident  by  a  characteristic  expiratory 
cough  and  inspiratory  whistling  sound  and  the  patient's  attitude  changes 
from  one  of  horrible  restlessness  and  fighting  for  air  to  one  of  peaceful 
quiet  and  a  desire  to  sleep. 


DIPHTHERIA  463 

The  patient  should  be  watched  intently  after  intubation. 

Occasionally  the  tube  is  coughed  up  and  with  it  a  membranous  cast 
of  the  larynx  and  reintubation  may  not  again  be  necessary. 

If  the  tube  is  coughed  up  and  dyspnoea  returns,  intubation  must  be 
repeated  using  the  same  tube  and  not  one  of  next  larger  size,  for  fear  of 
causing  pressure  necrosis  of  the  cricoid  cartilage. 

Indications  for  Intubation.  Laryngeal  diphtheria  is  diagnosed 
by  croupy  cough,  stridor,  'interference  with  voice  production,  increas- 
ing dyspnoea  and  cyanosis.  No  signs  of  pharyngeal  or  nasal  involvement 
need  be  present.  When  the  dyspnoea  has  so  far  progressed  that  there  is 
retraction  of  the  episternal  notch  and  supra  clavicular  regions  and  a  pulse 
that  disappears  with  each  inspiration,  intubation  is  indicated.  If  one 
wait  until  there  is  cyanosis  the  exhaustion  will  be  so  great  that  the 
chances  of  successful  intubation  are  greatly  diminished. 

Post-intubation  Treatment.  Our  first  apprehension  after  intuba- 
tion is  the  danger  of  expulsion  of  the  tube  during  a  fit  of  coughing  and 
constant  watching  is  necessary.  If  the  cough  is  troublesome,  the  croup 
kettle  and  the  use  of  antipyrin  or  small  doses  of  codeine  may  give  relief. 

The  next  difficulty  is  the  feeding  of  these  cases.  At  first  it  is  often 
difficult  for  the  patient  to  swallow,  particularly  liquids.  Milk  toast, 
thick  cereals,  custards  and  ice  cream  are  preferable  to  liquid  food.  To 
facilitate  swallowing  the  patient  may  be  fed  while  reclining  with  the 
head  lower  than  the  body  (Casselberry  Method).  When  even  this 
method  fails,  gavage  or  rectal  feeding  may  be  employed. 

EXTUBATION 

When  the  temperature  subsides,  usually  about  the  fourth  day,  it  is 
safe  to  see  if  the  child  can  do  without  the  tube.  The  sooner  the  tube  can 
be  removed  the  less  danger  there  is  of  pressure  injury  to  the  larynx. 

Procedure.  1.  Have  near  at  hand  an  introducing  instrument  with 
a  tube  of  the  same  size  as  the  one  to  be  removed. 

2.  Wrap  child  in  a  mummy  sheet  to  prevent  struggling,  and  insert 
mouth  gag. 

3.  Place  tip  of  left  index  finger  upon  head  of  tube  and  left  thumb 
against  cricoid  cartilage  externally. 

4.  Introduce  extractor,  parallel  to  median  line  of  tongue,  guided  by 
left  index  finger  until  one  is  sure  that  tip  is  within  lumen  of  tube. 

5.  Raise  handle   until  it  touches  the  upper  incisor  teeth,  then  the 
jaw  of  the  extractor  will  pass  well  within  the  lumen  of  the  tube.    Now 
press  the  lever  on  handle  and,  reversing  the  motions  used  in  intubation, 
remove  the  tube. 


464  TREATMENT  OF  ACUTE  INFECTIOUS  DISEASES 

The  secret  of  successful  intubation  or  extubation  is  in  keeping  the 
instruments,  throughout  the  whole  manipulation,  parallel  with  the 
median  line  of  the  tongue. 

Auto-extubation.  May  occur  early  or  late  in  the  disease.  When 
it  occurs  early,  on  third  or  fourth  day,  the  patient  has  usually  sufficiently 
recovered  to  be  able  to  go  without  the  tube.  When  it  occurs  later,  from 
tenth  day  to  third  or  fourth  week,  it  is  usually  persistent  and  tube  may 
be  coughed  out  as  many  as  thirty  times  in  twenty-four  hours.  This 
persistent  coughing  up  of  the  tube  is  due  to  a  perichondritis  at  the  cricoid 
level  and  therefore  the  tube  can  no  longer  be  held  in  place  by  the 
retention  swell  for  the  firm  cartilaginous  larynx  at  the  cricoid  level  is 
converted  into  a  collapsible  tube.  This  condition  occurs  in  from  3  to  5 
per  cent,  of  intubation  cases.  The  treatment  of  these  cases  is  by  a  bul- 
bous tracheal  tube  which  is  longer  than  the  O'Dwyer  tube  and  reaches 
well  down  into  the  trachea.  These  tubes  will  practically  put  a  stop  to 
auto-extubation. 

Tracheotomy.  For  this  procedure  one  should  have  recourse  to 
surgical  text-books. 

DIFFERENTIAL    DIAGNOSIS 

Spasmodic  Croup.  Sudden  onset  and  sudden  subsidence.  No 
aphonia.  No  progressive  dyspnoea  but  a  succession  of  attacks  during  the 
acute  stage  with  marked  improvement  during  the  intervals. 

Retropharyngeal  Abscess.  Absence  of  aphonia  but  there  is  a 
muffled  voice  with  a  throaty  stridor..  Dyspnoea  is  greater  when  mouth 
is  open.  Head  is  held  thrown  back.  Digital  examination  reveals  a 
fluctuating  mass  on  posterior  wall  of  pharynx. 

Foreign  Bodies.  Onset  is  very  sudden,  there  is  a  paroxysmal 
cough  and  violent  dyspnoea.  If  the  foreign  body  is  not  coughed  out 
but  becomes  impacted  death  may  rapidly  follow  from  occlusion  of 
the  glottis. 

Bronchopneumonia.  When  the  pneumonia  is  bilaterial  in  chil- 
dren, there  may  be  marked  retreaction  of  the  chest  and  sinking  in  of 
the  epigastrium.  There  is  absence  of  a  croupy  cough  and  the  different 
character  of  the  dyspnoea  together  with  the  physical  signs  in  the 
chest  clears  the  diagnosis. 

Subglottic  Edema.  May  give  rise  to  the  same  symptoms  as 
laryngeal  diphtheria  and  an  examination  of  the  larynx  is  necessary  to 
differentiate. 

Phlegmon  of  Glottis.  No  croupy  cough  or  aphonia.  Examination 
shows  marked  inflammatory  swelling  of  epiglottis  and  arytenoid  region. 


DIPHTHERIA  465 

Nervous  Diseases.  In  certain  acute  infections  as  poliomyelitis, 
superior  basilar  meningitis,  encephalitis  and  cerebellar  abscesses  there 
may  be  laryngeal  symptoms  due  to  irritation  of  the  basal  ganglia.  Dr. 
H.  L.  Lynah  has  reported  two  interesting  cases,  one,  a  case  of  cerebellar 
abscess  where  the  respiration  simulated  that  of  laryngeal  obstruction. 
Evacuation  of  the  abscess  relieved  the  respiratory  condition.  Another, 
diagnosed  as  laryngeal  diphtheria,  proved  at  autopsy  to  be  an  encepha- 
litis with  an  enormous  increase  of  fluid  in  the  ventricular  spaces. 

Recurrent  Laryngeal  Nerve  Paralysis  due  to  mediastinal  tumors 
simulates  laryngeal  diphtheria  but  is  differentiated  by  laryngoscopic 
examination.  In  this  condition  the  obstruction  is  below  the  larynx  and 
there  is  no  loss  of  laryngeal  function.  The  expiratory  dyspnoea  is  greater 
than  the  inspiratory  and  percussion,  X-ray  and  course  will  clear  the 
diagnosis. 

TREATMENT    OF  SYMPTOMS 

Fever.  A  high  temperature  is  not  characteristic  of  the  disease; 
on  the  contrary,  the  temperature  is  relatively  low.  Treatment  for  it, 
as  such,  is  not  indicated  and  antipyretics  are  absolutely  contraindicated 
on  account  of  their  depressant  effect  on  the  circulation.  Sponge  baths, 
luke  warm  or  cool  so  far  as  they  increase  the  patient's  comfort  may 
be  given. 

Angina.  In  many  cases  there  may  be  very  little  discomfort  in 
the  throat,  again  the  throat  and  mouth  may  be  extensively  involved, 
with  much  fetor,  while  with  the  invasion  of  other  organisms,  the  in- 
flammatory reaction  and  discomfort  may  be  much  increased. 

External  Applications.  Cold  or  heat  applied  to  the  neck,  pref- 
erably the  former,  afford  relief.  Cold  may  be  so  applied  in  the  shape 
of  the  ice-bag,  the  coil  or  compresses. 

Heat.  If  heat  is  found  the  more  grateful,  it  may  be  afforded 
by  the  use  of  hot  fomentations. 

Applications  to  the  Throat.  It  must  be  remembered  that  no 
applications  that  can  be  made  will  kill  the  organisms  concerned  and 
the  best  we  can  do  is  to  make  such  applications  as  preserve  the  maximum 
amount  of  cleanliness  of  the  part  and  so  lessen  the  likelihood  of  spreading, 
of  inviting  the  invasion  of  other  bacteria  or  of  permitting  decomposition 
and  putrefaction. 

We  must  remember,  however,  that  these  very  efforts,  unless  judi- 
ciously carried  out  may  do  damage  to  the  invaded  tissues  and  hasten 
the  very  processes  they  were  designed  to  prevent. 

Applications  are  made  by  the  gargle,  spray,  irrigation  or  swab.  A 
gargle  is  painful  and  does  not  reach  the  parts  most  affected  and  serves 


466  TREATMENT  OF  ACUTE  INFECTIOUS  DISEASES 

for  little  better  than  a  mouth  wash.  The  spray  is  a  better  method,  but 
by  all  odds  the  best  is  the  irrigation. 

The  best  irrigating  fluids  are  those  blandest  to  the  inflamed  mucous 
membranes,  such  as  sodium  chloride  in  physiological  solution  (one  dram 
to  the  pint)  or  2  per  cent,  boric  acid  solution  or  Dobell's  solution  diluted 
two  to  four  times.  It  should  be  as  hot  as  the  patient  can  comfortably 
stand  it,  100°  F.  in  a  child,  110°  F.  to  115°  F.  in  an  adult. 

A  fountain  syringe  or  irrigator  is  held  above  the  head  at  a  height 
sufficient  to  give  free  movement  to  the  stream,  but  not  force;  a 
nozzle  of  hard  rubber  or  metal,  or  in  older  children  a  catheter  may  be 
used. 

The  patient,  unless  the  case  is  of  the  mildest,  should  not  sit  up  in  bed, 
lest  cardiac  failure  should  occur,  but  lying  on  the  side  at  the  edge  of  the 
bed,  with  a  towel  about  the  neck  and  a  pus-basin  or  other  receptacle 
under  the  chin  to  catch  the  fluid.  In  older  patients  the  tongue  may  be 
depressed  by  a  wooden  or  glass  depressor  or  the  nozzle  may  be  inserted 
between  the  molars  and  the  stream  directed  in  various  directions. 

One  should  use  from  a  pint  to  a  quart  or  more.  If  the  mouth  is  foul 
they  may  be  given  every  two  or  three  hours,  in  less  severe  cases  three 
times  a  day. 

If  there  is  a  great  deal  of  mucus,  the  throat  may  receive  a  preliminary 
spraying  with  a  solution  of  sodium  bicarbonate  gr.  xx  to  the  ounce 
(1.30  Gm.-30  c.c.),  the  membranes  gently  touched  with  half  strength 
solution  of  hydrogen  dioxide  and  then  the  irrigations  be  given.  Sprays 
of  the  same  substances  as  the  irrigations  may  be  given  as  often  as  they 
afford  comfort.  No  measures  that  cause  pain  should  be  persisted  in. 

Many  authors  are  impressed  with  the  cleanly  appearance  afforded 
by  applications  of  Loffler's  solution.  (For  formula  see  Scarlet  Fever, 
Chap.  XVII.)  It  should  be  applied  with  a  swab  on  an  applicator  and 
held  pressed  against  the  membrane  not  swabbed  around.  This  may  be 
made  two  or  three  times  a  day.  Cracked  ice  held  in  the  mouth  gives 
much  relief  at  times. 

The  pain  of  swallowing  when  great  may  be  alleviated  by  the  appli- 
cation of  1  per  cent,  to  2  per  cent,  cocaine. 

In  very  foul  mouths  1  to  2000  permanganate  of  potash  may  be  used 
as  an  irrigation  before  using  the  saline. 

Nose.  Most  authorities  are  in  agreement  that  in  nasal  diph- 
theria, irrigations  are  indicated.  McCollom,  however,  deprecates  the 
procedure,  because  he  is  convinced  that  the  number  of  middle  ear  cases 
increase  under  it. 

It  would  seem,  however,  that  in  the  great  danger  attending  these 
cases,  with  involvement  of  the  rapidly  absorbing  naso-pharynx  that 


DIPHTHERIA  467 

some  means  of  cleansing  the  area  involved  were  necessary  and  that 
irrigation  was  the  only  efficacious  means. 

The  same  solutions  may  be  used  as  in  the  throat,  namely,  warm 
physiological  salt  solution,  2  per  cent,  boric  acid  solution  or  DobelPs 
diluted  one  to  four  times. 

A  fountain  syringe,  held  at  such  a  height  as  to  just  force  the  solution 
through  in  a  gentle  stream  and  a  glass  nozzle  or  a  small  rubber  catheter, 
with  holes  cut  in  the  side  are  used.  It  should  be  done  as  often  as  every 
two  hours  in  severe  cases  with  profuse  excoriating  discharges,  less  often 
in  the  milder  cases. 

If  a  fountain  syringe  is  not  at  hand  or  difficulty  is  experienced  in  its 
use,  a  piston  syringe  may  be  substituted. 

The  patient  should  keep  the  mouth  open  during  the  procedure  and  the 
irrigation  should  be  directed  first  to  the  side  most  obstructed,  so  that 
a  damming  up  behind  the  obstruction  will  not  force  the  fluid  back  into 
the  Eustachian  tube. 

If  irrigation  is  objected  to,  applications  gently  made  with  a  swab  and 
sprays  must  take  its  place.  Calomel  may  be  insufflated. 

Where  there  is  much  hemorrhage  from  the  nose,  adrenalin  in  dilution 
of  1  to  2000  to  3000  may  be  used ;  in  some  cases  dry  packing  of  the  nares 
is  necessary  or  if  that  fails  the  gauze  used  for  packing  may  be  saturated 
with  adrenalin,  l.to  3000. 

Thromboplastin  and  Kephalin  contain  thromboplastin  from  brain 
tissue  which  is  a  coagulant.  They  may  be  applied  locally  to  the  bleeding 
point  on  cotton  or  gauze  and  left  in  situ  for  5  to  10  minutes.  Coagulen 
is  a  preparation  from  blood  platelets  put  up  as  dry  powder.  A  10  per 
cent,  solution  of  this  is  applied  to  the  bleeding  vessel  on  cotton  or  gauze. 
Care  must  be  used  in  removing  the  application  lest  the  blood  clot  formed 
be  loosened.  This  may  be  eliminated  by  not  allowing  the  cotton  to  dry 
and  leaving  some  of  the  solution  in  situ. 

Hemostatic  serum  (hemoplastin)  may  be  applied  on  gauze  or  cotton 
packing.  If  it  does  not  stop  the  bleeding  after  5  to  10  minutes,  1/2  to 
2  c.c.  of  the  clear  solution  may  be  injected  locally  at  the  site  of  the 
hemorrhage. 

Cardio-Vascular  Apparatus.  The  prophylactic  treatment  of 
circulatory  failure  lies  in  the  promptness  and  thoroughness  of  the 
serum  treatment. 

No  complication  in  diphtheria,  excepting  laryngeal  involvement 
and  its  sequelae,  is  so  grave  as  that  which  includes  the  circulatory  ap- 
paratus. 

One  may  distinguish  an  early  and  a  late  form  of  circulatory  dis- 
turbance. The  early  form  manifests  the  same  evidences  of  circulatory 


468  TREATMENT  OF  ACUTE  INFECTIOUS  DISEASES 

inefficiency  as  one  sees  in  any  other  acute  infection  and  is  in  the  main  due 
to  the  same  cause,  namely,  a  vaso-motor  failure,  referable  particularly 
to  the  vaso-motor  center.  However,  it  must  be  said  that  such  experi- 
mental evidence  as  we  have  points  to  a  greater  implication  of  the  cardiac 
muscle  in  diphtheria  than  in  the  case  of  the  other  acute  infections;  but 
still,  it  is  the  vaso-motor  center  that  has  to  be  chiefly  considered  in 
this  disease  too. 

What  has  been  said  about  the  cardio-vascular  apparatus  in  discussing 
scarlet  fever  (see  Chap.  XVII),  is  applicable  in  all  details  both  with 
reference  to  its  etiology,  its  symptomatology  and  its  treatment  here,  and 
the  reader  may  consider  that  discussion  as  referred  to  this  subject. 

These  circulatory  disturbances  may  come  on  at  any  time  in  the  first 
two  weeks,  depending  on  the  severity  of  the  infection,  but  at  the  end  of 
the  second  week  up  to  the  fourth  week,  seldom  later  there  occurs  a 

Late  circulatory  failure,  which  has  been  attributed  to  degen- 
erative changes  in  the  heart,  especially  its  nervous  mechanism  and 
has  been  spoken  of  as  pneumogastric  paralysis. 

It  comes  in  convalescence,  at  a  time  when  other  nerve  degenerations 
are  made  manifest. 

It  is  a  most  serious  condition,  often  abrupt,  usually  first  appreciated 
by  an  attack  of  vomiting.  This  becomes  repeated,  is  accompanied 
by  precordial  distress,  epigastric  pain  and  tenderness,  dyspnoea,  great 
restlessness,  sometimes  a  clear  mind,  sometimes  marked  cerebral  disturb- 
ance, syncopal  attacks,  pallor,  sweating,  very  feeble  pulse,  strikingly 
slow,  though  sometimes  rapid,  and  death. 

Sometimes  the  first  premonition  is  given  by  a  sudden  change  of  the 
pulse  rate  to  a  considerably  higher  or  slower  rate. 

Occasionally  one  encounters  such  functional  disturbances  as  auricular 
fibrillation  and  heart  block.  The  latter  may  be  attributable  to  degenera- 
tive changes  in  the  bundle  of  His  though  this  is  not  always  demon- 
strated at  autopsy. 

One  of  the  most  ominous  facts  about  the  heart  of  diphtheria  is  the 
tendency  to  sudden  syncope  and  death  and  coming  out  of  a  clear  sky, 
without  a  particle  of  warning  in  many  cases,  even  when  assiduously 
watched  for.  Nearly  every  writer  of  note  frankly  admits  his  inability  to 
give  a  reasonable  explanation  for  this  appalling  accident.  There  may  be 
lesser  manifestations  with  very  slow  and  irregular  heart  as  the  major 
evidence  of  disturbance  and  recovery  take  place,  but  one  is  never  sure  of 
the  result  and  faces  the  possibility  of  a  turn  for  the  worse  or  a  sudden 
issue. 

The  early  and  characteristic  vomiting,  the  cerebral  disturbance, 
the  vaso-motor  implication,  the  association  with  other  paralyses  and  its 


DIPHTHERIA  469 

time  of  onset  has  suggested  the  sudden  death  as  a  manifestation  of 
cerebral  degeneration  rather  than  essentially  cardiac.  But  that  there  is 
a  toxic  effect  wrought  on  the  myocordium  not  evidenced  by  histological 
findings  or  by  the  character  of  the  histological  changes  found  is  shown 
by  the  sudden  failure  of  the  organ  when  neither  sign  nor  symptoms  are 
evidenced  and  the  child  has  begun  to  resume  normal  activities. 

Diphtheria  is  another  disease  in  which  toxic  arteriosclerosis  occurs  as 
is  shown  by  slight  increase  in  blood  pressure  and  increase  in  second 
aortic  sound  and  thickened  palpable  arteries.  This  is  likely  to  disappear 
after  a  few  weeks.  Furthermore  aortitis  occurring  after  diphtheria 
has  been  often  noted.  It  is  said  to  be  a  necrosis  confined  to  the 
media. 

The  treatment  begins  with  efficient  and  prompt  serum  administration 
at  the  earliest  moment  of  diagnosis;  it  continues  by  great  care  to  avoid 
even  slight  physical  exertion  during  and  well  into  convalescence  in  all 
cases,  even  the  mild,  but  especially  those  that  have  been  very  toxic  and 
when  there  have  followed  nerve  paralyses,  or  there  is  evidence  of  kidney 
involvement.  Therefore  daily  examinations  should  lay  stress  on  the 
deviation  from  the  normal  heart  rate,  high  or  low,  muffling  or  splitting  of 
heart  sounds,  irregularity  of  the  pulse  and  least  of  all  murmurs;  upon 
subjective  sensations  such  as  dypsncea,  precordial  distress,  gastric  nausea 
or  vomiting,  syncope  or  even  pallor.  It  must  be  further  emphasized 
that  the  later  the  minor  cardiac  disturbances  such  as  changes  in  rate, 
rhythm  or  sound  occur,  the  more  serious  is  the  cardiac  complication.  It 
should  be  further  emphasized  that  the  subjective  disturbances  noted 
above  are  even  more  ominous  than  the  objective. 

The  condition  is  most  dire  and  sudden  death  threatens  with  the 
least  exertion,  such,  for  example,  as  is  induced  by  vomiting  or  sitting  up 
in  bed,  or  mental  excitement. 

For  this  reason  absolute  rest  is  imperative  and  nothing  will  do  so 
much  to  secure  and  relieve  the  distress  and  pain  and  anxiety  as  morphine 
sulphate,  hypodermically,  every  four  hours  if  needed,  in  such  doses  as  to 
effect  the  purpose;  e.  g.,  gr.  1/48  (0.0015  Gm.)  in  the  child  of  two  years, 
gr.  1/24  (0.002  Gm.)  to  gr.  1/16  (0.004  Gm.)  at  six  and  gr.  1/12  (0.005 
Gm.)  or  gr.  1/8  (0.008  Gm.)  at  twelve  years. 

With  late  cardiac  manifestations  food  must  be  cut  down  in  quantity 
especially  at  any  one  feeding;  less  food  given  at  more  frequent  intervals. 
This  applies  when  no  gastric  symptoms  have  occurred.  On  the  appear- 
ance of  gastric  disturbance,  food  by  the  mouth  must  be  stopped  as  the 
vomiting  makes  its  retention  impossible  and  is  perhaps  aggravated  by 
it.  Such  nourishment  as  is  given  must  be  by  the  rectum.  Procedures  of 
all  kinds,  about  the  mouth,  nose,  etc.,  must  be  decreased  to  a  minimum. 


470  TREATMENT  OF  ACUTE  INFECTIOUS  DISEASES 

As  nutrient  enemata  one  may  use  the  following : 

Nutrient  Enemata. 

200  c.c.  peptonized  milk . 140  calories 

2  eggs 120      " 

Physiological  saline  solution 500  c.c. 

Introduce  by  Murphy  drip.    (Bloodgood.) 
or 

500  c.c.  milk 

45  Gm.  lactose. 600  to  650  calories 

30  c.c.  whiskey  or  brandy 

Add  salt  3i  to  500  c.c 

Give  slowly  as  above. 

Heat  over  the  precordium  may  allay  pain  and  distress  to  some  degree. 

There  is  no  unanimity  of  opinion  about  drug  administration  in  this 
condition. 

I  believe,  however,  that  those  drugs  that  we  use  in  circulatory  failure 
earlier  in  the  disease  and  hi  other  acute  infectious  diseases  should  be  used 
here;  caffeine,  camphor,  strychnine,  which  affect  the  medullary  centers, 
adrenalin  (epinephrin)  and  digitalis.  If  we  accept  the  theory  of  pneumo- 
gastric  degeneration  in  this  condition  and  fear  the  effect  of  digitalis  on 
this  structure,  we  may  administer  atropine  with  the  digitalis,  to  eliminate 
the  vagus  influence,  giving  gr.  1/100  (0.0006  Gm.)  of  the  sulphate  with 
each  dose  of  the  digitalis. 

Of  the  vaso-motor  stimulants  I  have  said  my  favorites  are  caffeine 
and  camphor.  The  rationale  of  caffeine  is  discussed  under  scarlet  fever. 
(See  Chap.  XVII.)  It  may  be  used  hypodermically  as  the  double  salt  of 
sodium  salicylate  or  sodium  benzoate  and  caffeine.  For  a  child  of  5 
years  the  dose  is  1/2  to  1  grain  (0.030-0.060  Gm.) ;  at  11  years  1-2  grains 
(0.060-0.120  Gm.);  adult  5  grains  (0.33  Gm.). 

Camphor,  while  it  has  little  obvious  effect  on  either  a  normal 
heart  or  vaso-motor  center,  has  been  demonstrated  experimentally  to 
produce  a  stimulating  effect  on  both  when  they  have  been  depressed 
by  poisons.  Upon  the  heart  it  seems  to  have  a  marked  effect  on  the 
function  of  irritability.  Its  mode  of  administration  in  circulatory 
failure  and  its  results  are  found  under  scarlet  fever.  (See  Chap.  XVII.) 
It  is  best  given  in  olive  oil  or  sesame  oil  hypodermically.  The  dose 
at  5  years  is  1/2  to  1  grain  (0.030-0.060  Gm.);  at  11  years  1-2  grains 
(0.060-0.120  Gm.);  adults  3  grains  (0.2  Gm.). 

Strychnine :  The  dose  of  the  sulphate  is  at  5  years  gr.  1/200-1/100 
(0.0003-0.0006  Gm.);  at  11  years  gr.  1/100-1/80  (0.0006-0.00075  Gm.); 
adults  gr.  1/60-1/30  (0.001-0.002  Gm.). 

An  enteroclysis  of  hot  salt  solution  3i  to  Oi  (4  Gm.  to  500  c.c.)  may  be 


DIPHTHERIA  471 

of  great  value  in  collapse  or  on  the  occasion  of  syncopal  attacks.  It 
should  be  given  with  a  rectal  tube,  to  which  is  attached  a  Y  tube,  one 
branch  of  the  Y  being  attached  to  a  rubber  tube  to  carry  off  the  water, 
while  the  other  is  attached  to  the  syringe.  By  pinching  the  discharge 
tube  the  amount  in  the  bowel  and  its  discharge  can  be  regulated.  This 
apparatus  can  be  utilized  with  little  disturbance  to  the  patient,  a  matter 
of  the  greatest  importance  during  the  attack. 

The  hot  saline  raises  the  body  heat  which  is  subnormal  as  a  rule  and 
by  direct  contact  with  the  mucous  membrane  over  a  considerable  area 
affords  a  powerful  stimulant  to  the  peripheral  vaso-motor  supply  of  the 
splanchnics;  thus  raising  blood  pressure  effectually.  A  cup  of  hot  coffee 
may  well  be  added  to  the  saline.  The  temperature  of  the  fluid  should 
be  110°  F.  to  115°  F. 

A  saline  injected  into  the  tissues,  at  a  temperature  of  100°  F.,  that  is, 
a  hypodermoclysis,  is  another  excellent  stimulant. 

Cold  Air.  The  splendid  effect  of  cold  air  upon  the  circulatory 
system  obtains  in  this  disease  as  well  as  in  other  acute  infections.  (See 
Open  Air  Treatment  of  Pneumonia,  Chap.  IX.) 

It  must  be  mentioned  that  most  of  the  authors  advise  the  use  of 
alcohol  as  a  stimulant,  Sss.  to  $i  a  day  in  divided  doses  in  children  and 
more  in  adults  as  a  cardiac  stimulant  and  as  having  some  beneficial 
effect  on  the  toxemia. 

I  am  opposed  to  this  teaching,  both  because  it  seems  irrational  to 
add  day  after  day  to  the  nerve  tissues  undergoing  the  degenerative 
effects  of  the  toxin  a  substance  which  is  itself  capable  of  inducing  a 
similar  process  and  because  I  do  not  believe  it  is  a  true  stimulant. 

That  it  has  some  food  value  cannot  be  denied,  but  that  it  has  advan- 
tages Over  the  other  class  of  foodstuffs  in  this  condition  is  more  than 
questionable. 

Paralyses.  Upon  the  nerve  structures  the  poison  of  this  dis- 
ease has  a  selective  action.  Nearly  all  the  nerves  are  susceptible  to  its 
action,  but  some  more  than  others. 

The  results  are  rather  partial  disability,  paresis,  than  total  paralysis 
and  the  continuance  of  this  disability  is  brief.  The  importance  of  the 
lesion  lies  in  the  vital  significance  of  the  nerve  structure  affected,  such  as 
the  medullary  centers  or  the  vagus  nerve. 

The  preventive  treatment  depends  on  the  promptness  with  which 
antitoxin  is  administered,  for  once  the  toxin  is  in  combination  with 
the  nerve  tissue  there  is  no  known  way  of  ousting  it  and  antitoxin  is 
believed  to  be  ineffectual  in  achieving  such  a  desideratum. 

It  depends,  too,  on  the  sufficiency  of  the  early  doses,  for  it  seems  as 
if  the  neurotoxic  substance  was  that  portion  of  the  toxin  designated 


472  TREATMENT  OF  ACUTE  INFECTIOUS  DISEASES 

the  toxon,  which  has  a  less  avidity  for  the  antitoxin  than  the  rest  of 
the  toxin  particle  and  hence  is  not  neutralized  until  the  rest  is 
satisfied. 

Another  preventive  measure,  preventive  rather  of  the  disaster  than  of 
actual  nerve  involvement,  is  to  assume  that  the  nerve  may  be  affected 
and  insist  on  absolute  rest  and  recumbency  in  all  but  the  very  mildest 
cases  and  even  in  these  to  realize  that  risk  is  not  eliminated. 

The  effects  of  the  toxin  on  the  nerve  structures  are  not  evident  until 
it  has  time  to  produce  a  certain  degree  of  degeneration,  so  that  the 
clinical  evidences  of  paralysis  are  not  as  a  rule  manifest  until  the  end 
of  two  weeks. 

The  likelihood  of  its  occurrence  is  increased  in  proportion  to  the 
severity  of  the  disease.  The  earliest  evidences  are  seen  in  the  palate 
and  the  heart;  hence,  the  insistency  on  rest  and  recumbency  when  the 
patient  is  seemingly  entered  upon  convalescence.  The  plain  facts  of  the 
dangers  and  risks  in  a  case  at  this  time  must  be  told  the  parents  or  the 
patient  if  an  adult  or  older  child. 

It  is  more  common  in  young  children,  but  in  pure  laryngeal  cases 
is  relatively  rare. 

The  incidence  of  the  complications  is  set  at  figures  that  range  from 
11  per  cent,  to  40  per  cent. 

Heart  involvement  has  just  been  discussed. 

Soft  Palate.  This  is  the  most  frequent  of  the  paralyses.  It  is 
important,  too,  because  of  the  difficulty  of  feeding  in  decided  cases, 
as  the  food  will  regurgitate  through  the  nose. 

This  entails  feeding  by  gavage,.  through  the  stomach  tube,  which 
may  be  more  readily  accomplished  in  the  adult  or  through  the  nose 
in  a  child.  This  manner  of  feeding  will  not  be  continued  long,  because 
of  the  brief  period  of  paresis. 

Pharynx.  When  the  pharyngeal  nerves  are  affected,  swallowing 
is  rendered  difficult  and  choking  may  ensue.  Here  again,  the  feeding 
by  the  tube  is  indicated. 

Respiratory  Muscles.  Either  set,  intercostals  or  diaphragm 
or  both,  may  be  involved.  Everything  to  lessen  respiratory  effort, 
such  as  weight  of  clothes  or  doubled  up  position  should  be  avoided. 
Not  infrequently,  affection  of  the  pharyngeal  muscles  and  larynx  occur 
simultaneously.  Secretions  collect  in  the  bronchi  or  food  particles  gain 
entrance  and  quantities  of  secretions  gather  in  the  pharynx.  The  cough 
is  ineffectual  to  expel  these  secretions  and  foreign  body  pneumonia 
threatens.  The  foot  of  the  bed  should  be  raised  a  trifle,  but  not  enough 
for  the  pressure  of  the  abdominal  viscera  on  the  diaphragm  to  further 
embarrass  respiration.  The  secretions  from  the  pharynx  may  be  as- 


DIPHTHERIA  473 

pirated  off  with  a  small  rubber  tube  and  a  syringe  and  the  swab  of  cotton 
on  a  dressing  forceps  or  other  form  of  applicator  may  be  used. 

Atropine  sulphate  gr.  1/100  (0.0006  Gm.)  three  or  four  times  a  day  may 
lessen  the  secretions.  Occasional  compression  of  the  chest  may  help 
to  expel  the  bronchial  contents.  The  other  forms  of  paralysis,  such  as 
the  oculo-motor,  the  facial  and  that  of  the  extremities  (the  upper  are 
very  rare)  need  no  especial  treatment,  considering  the  natural  progress 
of  events. 

The  only  drug  that  it  seems  rational  to  administer  is  strychnine, 
in  doses  of  gr.  1/400  (0.00015  Gm.)  to  gr.  1/150  (0.00045  Gm.)  at  two 
years,  and  gr.  1/100  (0.0006  Gm.)  to  gr.  1/40  (0.0015  Gm.)  at  twelve 
yeais  three  or  four  times  a  day. 

Nephritis.  There  seems  to  be  a  considerable  difference  of  opin- 
ion about  the  frequency  of  nephritis  in  diphtheria  and  its  clinical  im- 
portance. 

There  is,  as  in  every  acute  infection,  a  trace  of  albumin  that  is  ref- 
erable to  the  acute  degeneration  of  the  epithelium  of  the  tubules  and 
tufts;  but  there  may  also  be  an  acute  diffuse  nephritis,  with  no  con- 
stancy of  lesion,  that  is  the  glomerular  changes  may  predominate  in  one 
and  the  interstitial  in  another.  There  seems,  however,  to  be  a  good  deal 
of  tubular  involvement  as  a  rule  with  an  abundant  albuminuria.  Dropsy 
is  rare  and  uraemia  not  common.  In  severe  cases  anuria  may  prove  fatal. 
Serious  kidney  complications  come  on  earlier  in  diphtheria  than  in  scarlet 
fever,  are  less  serious  both  during  the  disease  and  later.  The  urine 
should  be  examined  daily. 

The  treatment  again  begins  with  early  and  effective  serum  therapy. 
When  developed,  however,  it  is  to  be  treated  like  the  nephritis  of  scarlet 
fever  (see  Scarlet  Fever,  Chap.  XVII),  but  hot  packs  are  less  well  borne 
as,  indeed,  are  any  measures  that  entail  much  manipulation  with  conse- 
quent strain  upon  the  heart. 

OTHER   COMPLICATIONS 

Bronchopneumonia.  This  complication  is  to  be  particularly  dreaded 
in  the  laryngeal  cases  which  come  to  operation.  It  is  to  be  treated  like 
any  bronchopneumonia.  (See  Pneumonia  and  Streptococcus  Pneumonia, 
Chaps.  IX  and  X.) 

Adenitis  may  occur  in  severe  angina  and  in  mixed  infections. 
It  is  treated  with  the  application  of  ice  and  incision  as  soon  as  fluctua- 
tion is  detected. 

Otitis  is  said  to  occur  in  4  per  cent,  of  the  cases.  It  may  be 
followed  by  mastoiditis,  sinus  involvement  or  cerebral  invasion.  (For 
treatment,  see  Otitis  in  Scarlet  Fever,  Chap.  XVII.) 


474  TREATMENT  OF  ACUTE  INFECTIOUS  DISEASES 

Convalescence.  In  no  other  disease  must  the  convalescence  be 
handled  with  more  care  and  discretion. 

The  dangers  of  cardiac  failure,  even  when  there  have  been  no  clinical 
evidences  of  the  involvement  of  that  organ  and  even  in  mild  cases  make 
it  imperative  to  explain  the  situation  fully  to  the  patient  or  in  the  case  of 
children  to  the  parents. 

If  the  case  has  been  mild  the  patient  may  be  propped  up  in  bed  at 
the  end  of  the  third  week  and  sit  up  in  bed  at  the  end  of  the  fourth  and  a 
little  later  be  put  in  a  chair  and  then  allowed  to  walk  in  a  few  days.  All 
this  time,  the  effect  on  the  circulation  must  be  watched. 

Some  authors  make  it  a  rule  in  mild  cases  to  allow  the  patient  out  of 
bed  a  week  after  the  throat  has  cleared  up,  especially  applying  the  rule 
to  adults  or  those  in  whom  the  tonsil  alone  has  been  mildly  affected. 

All,  however,  are  in  agreement  that  in  severe  cases  the  patient  should 
remain  in  bed  six  or  eight  weeks  and  in  no  case  be  allowed  up  as  long  as 
there  are  signs  of  heart  involvement. 

When  the  patient  is  up  good  food  and  good  air  are  of  prime  importance. 
For  the  anemia  that  in  some  degree  is  sure  to  have  followed  iron  may  be 
used.  Blaud's  pill,  made  fresh,  or  the  Vallet's  mass  in  doses  of  gr.  iii  to 
gr.  v  (0.20-0.30  Gm.)  three  times  a- day. 

Strychnine  Sulphate  in  doses  of  gr.  1/200  (0.0003  Gm.)  to  a  child  of 
five  years  and  gr.  1/40  to  gr.  1/30  (0.0015-0.002  Gm.)  to  an  adult 
three  times  a  day. 

Quinine  in  doses  of  gr.  1  (0.060  Gm.)  three  times  a  day  have 
been  credited  with  tonic  properties.  It  can  be  combined  with  the  strych- 
nine. 

In  children  Cod  Liver  Oil,  in  doses  of  1/2  to  1  dram  (2-4  c.c.)  three 
times  a  day  is  given  for  the  same  purpose. 

Release  from  Quarantine.  A  patient  should  not  be  released 
from  quarantine  until  two  successive  cultures  taken  from  the  sites  of 
the  lesion  are  negative.  Three  are  safer  at  three-day  intervals  and  an 
effort  should  be  made  to  get  material  from  the  crypts  of  the  tonsils  by 
gentle  expression  of  their  contents  with  a  spatula.  Cultures  should  also 
be  taken  from  the  naso-pharynx  and  nose.  In  the  larger  number  this 
occurs  in  a  week  after  the  throat  is  cleared  from  membrane,  but  it  may  be 
three,  four,  five  or  more  weeks  before  the  cultures  are  returned  negative. 

When  the  bacteria  are  persistent  an  effort  may  be  made  to  rid  the 
throat  or  nose  of  them  by  a  spray,  irrigation  or  application  of  an  anti- 
septic. Holt  advises  bichloride  1  to  10,000  mixed  with  glycerin  one  part 
in  eight.  This  is  rarely  successful.  See  Carriers. 

If  the  organisms  are  not  to  be  gotten  rid  of  by  such  means,  the  cultures 
should  be  tested  for  their  virulency. 


DIPHTHERIA  475 

On  release  from  quarantine  the  patient  should  be  given  a  bath  with 
warm  water  and  soap  and  a  shampoo  with  the  same.  This  should 
be  followed  by  a  bath  of  1  to  5000  bichloride  of  mercury. 

Sterilization  and  Fumigation.  For  discussion  of  terminal  fumi- 
gation, see  Scarlet  Fever,  Chap.  XVII.  The  disinfection  is  to  be  car- 
ried out  as  in  a  case  after  scarlet  fever:  the  washable  clothing  and  linen 
should  be  boiled  for  an  hour  after  soaking  over  night  in  carbolic  1  to  50 
to  1  to  20.  Mattresses,  blankets,  pillows  and  unwashable  clothes  may 
b.e  subjected  to  steam  under  pressure.  If  not  obtainable,  submitted  to 
formaldehyde  gas. 

Articles  of  no  value  and  all  toys  should  be  burned  or  destroyed. 

Articles  made  of  metal  or  china  ware  may  be  immersed  in  1  to  20 
carbolic  acid. 

All  the  woodwork,  the  floor,  the  ceiling  and  walls  should  be  rubbed 
down  with  cloths  wet  in  1  to  2000  bichloride  of  mercury. 

The  room  should  then  be  fumigated  with  formaldehyde  gas.  The 
room  must  be  sealed  with  strips  of  paper  pasted  over  cracks  and  holes 
and  the  gas  generated  from  one  of  the  numerous  devices  on  the  market, 
such  as  paraldehyde  candles  and  left  closed  twelve  to  twenty-four  hours. 

McCollom  recommends  the  method  of  the  Maine  State  Board  of 
Health.  This  consists  in  putting  potassium  permanganate  (commercial) 
in  a  pan  or  other  receptacle  and  pouring  over  it  formalin  (40  per  cent.). 
It  is  used  in  the  proportions  of  6  1/2  ounces  of  the  permanganate  to  1 
pint  of  formalin.  This  quantity  will  fumigate  500  cubic  feet  of  space. 

The  room  should  then  be  repainted,  repapered  and  recalcimined. 

In  case  of  death,  the  funeral  should  be  private,  the  body  wrapped  in 
strong  antiseptics  and  the  coffin  sealed. 

Carriers.  The  detection,  disposal  and  treatment  of  carriers  con- 
stitute the  most  serious  problem  in  combating  the  disease.  It  is  the 
carriers  that  perpetuate  the  disease  and  they  constitute  such  a  con- 
siderable number  of  the  community,  often  entirely  unsuspected  either  by 
themselves  or  others,  that  their  elimination  can  be  achieved  only  by 
stamping  out  the  disease  through  rendering  a  community  immune. 

The  examination  of  the  upper  ah*  passages  of  large  numbers  of  the 
civil  population  lead  us  to  the  conclusion  that  about  1  per  cent,  are 
carriers;  so  far  as  it  can  be  determined  one-half  of  these  have  had  no 
contact  with  cases  of  diphtheria. 

Happily,  not  all  these  carriers  harbor  virulent  organisms.  The  per- 
centage of  virulent  organisms  depends  on  previous  contact  with  the 
disease. 

Wadsworth  found  that  carriers  who  had  had  the  disease  yielded 
90  per  cent,  of  virulent  organisms  from  the  day  of  onset  up  to  one  year; 


476  TREATMENT  OF  ACUTE  INFECTIOUS  DISEASES 

that  healthy  contacts,  that  is,  individuals  who  had  been  in  touch  with 
the  disease  during  an  epidemic  but  had  not  themselves  had  it,  showed 
80  per  cent,  of  virulent  bacilli,  while  among  healthy  non-contact  carriers 
only  10  per  cent,  of  the  organisms  were  virulent. 

Studies  of  doctors  and  nurses  in  contact  with  diphtheria  demonstrate 
a  considerable  number  of  carriers. 

A  few  important  points  to  remember  about  carriers  are  as  follows; 
A  single  negative  culture  has  been  shown  over  and  over  again  to  be 
fallacious.  The  surface  of  the  tonsils  and  naso-pharynx  may  be  clear 
when  the  deep  crypts  of  the  tonsils  are  still  infected. 

Nasal  cultures  should  be  taken  in  each  instance  as  well  as  throat 
cultures.  In  one  large  series  of  carriers  over  25  per  cent,  of  nasal  cultures 
were  positive. 

Chronic  carriers  are  such  by  virtue  of  some  pathologic  condition  of 
the  upper  air  passage  or  accessory  sinuses.  In  the  great  majority  of 
cases  the  bacilli  are  to  be  found  in  the  tonsils,  often  in  both  tonsils  and 
nose;  occasionally  hi  nose  alone;  next  is  the  naso-pharynx. 

Cultures  from  chronic  carriers  should  be  tested  for  virulency.  This 
is  done  by  injecting  a  guinea-pig  intracutaneously  with  cultures  of 
the  organism.  Virulent  bacilli  at  the  end  of  24  to  48  hours  give  rise  to  an 
area  of  redness  and  induration  followed  later  by  necrosis. 

Cats  and  dogs  may  be  carriers  and  for  that  reason,  if  for  no  other, 
should  be  excluded  from  the  sick-room. 

Treatment.     Operative  and  non-operative. 

Non-operative  treatment  has  universally  failed.  Sprays  of  all  kinds, 
argyrol,  DobelTs  solution,  Dichloramin  T,  Dakin's  solution,  crystal 
violet,  antitoxin  in  water  have  all  proved  equally  ineffectual. 

Operative — Correcting  the  condition  that  affords  a  pathologic  basis, 
is  the  only  measure  that  promises  success.  All  these  cases  should  be 
submitted  to  examination  by  a  competent  nose  and  throat  man.  Dis- 
eased tonsils  should  be  enucleated  and  adenoids  removed,  septum 
deformities,  erosions  or  other  abnormalities  receive  attention,  and  acces- 
sory sinus  disease  be  corrected. 

Patients  with  atrophic  rhinitis  and  other  chronic  inflammation  of  the 
nasal  passages  prove  the  most  persistent  carriers. 

It  is  interesting  that  all  chronic  carriers  seem  to  give  a  negative  Schick. 

Diphtheria  cases  should  show  3  negative  cultures  at  3-day  periods 
before  discharged. 

Prophylaxis.  The  subject  of  prophylaxis  has  been  covered  on 
the  sections  on  Schick  reaction,  active  immunization  and  carriers. 


DIPHTHERIA  477 

SUMMARY 

In  the  case  of  children  examine  the  throat  as  a  routine  in  all  condi- 
tions. 

Taking  of  cultures. 

In  all  inflammations  of  the  throat  in  a  child,  whatsoever  be  the 

clinical  diagnosis  and  howsoever  mild,  take  a  culture  for  Klebs- 

Loffler  bacilli. 
Persistent  and  especially  bloody  and  excoriating  nasal  discharges  in 

children  demand  a  culture. 
Laryngitis,  especially  of  a  croupy  character  and  more  particularly 

croup  lasting  into  the  day  makes  a  culture  necessary. 
For  technique  of  taking  culture,  see  text. 

Disposition  of  the  family. 

Other  children  in  family  kept  from  school. 

Adults  in  family  kept  from  contact  with  children. 

Health  authorities  should  be  notified. 

Authorities  should  inspect  the  school  or  suspected  groups. 

Children  should  be  isolated  and  cultures  taken  from  throats  and 

nose. 
Adults  should  submit  to  the  same  procedure,  as  they  may  become 

carriers. 

S chick  reaction  should  be  done  on  all  members  of  the  family. 
All  the  children  and  adults  reacting  positively  to  the  S  chick  should 

be  immunized  at  once. 
Immunizing  dose.    (Read  text.) 

Infants       500  units. 

Children  1,000  units. 

Adults     1,000  units. 
Children  whose  cultures  are  negative  should  be  removed  from  the 

home  if  the  patient  remains  there. 
If  these  children  cannot  be  removed  and  react  positively  to  the 

S  chick  test,  they  should  have  the  immunizing  dose  repeated  every 

three  weeks;  every  two  weeks  is  safer. 

(For  particulars  see  below  under  immunizing  dose.) 
Children  having  a  positive  culture  should  be  isolated,  but  never 

with  the  patient. 
If  case  cannot  be  isolated  at  home  he  should  be  removed  to  the 

hospital. 
Schick  test.    (See  text.) 

Should  be  done  on  all  members  of  the  family. 
Active  immunization,  see  text. 

Should  be  done  on  all  those  reacting  positively  to  Schick. 

Room. 

(See  Room  under  summary  in  Scarlet  Fever,  Chap.  XVII.) 


478  TREATMENT  OF  ACUTE  INFECTIOUS  DISEASES 

Nurse. 

Schick  test. 

Active  immunization,  if  Schick  is  positive;  both  passive  and  active. 

(See  Nurse  under  summary  in  Scarlet  Fever,  Chap.  XVII.) 

Special  precautions  to  avoid  infection  by  cough  or  sneeze  in  treat- 
ing throat  or  nose. 

Secretions  should  be  burned  at  once. 

Nurse  should  use  mild  sprays  of  boric  acid  2  per  cent,  to  4  per  cent., 
or  half  strength  Dobell's  solution;  but  no  astringents. 

Should  receive  an  immunizing  dose  of  1000  units  every  three  weeks 
and  better  every  two  weeks. 

Should  avoid  coming  in  contact  with  children  when  off  duty. 

Should  avoid  close  contact  with  others,  realizing  danger  of  her  cough- 
ing, sneezing  and  kissing. 

Physician. 

Should  submit  to  Schick  test  and  active  immunization  if  Schick  is 

positive. 

(See  Physician  under  summary  of  Scarlet  Fever,  Chap.  XVII.) 
Should  use  mild  sprays  but  no  astringents. 
If  especially  exposed,  as  by  a  cough  into  his  face,  should  receive  an 

immunizing  dose. 
Should  realize  that  he  may  be  a  carrier. 

Precautions  in  the  sick-room. 

(See  same  in  summary  of  Scarlet  Fever,  Chap.  XVII.) 
Temperature  of  room,  same  as  in  Scarlet  Fever.    (See  Chap.  XVII.) 

Bed. 

(See  Chap.  IX.) 

Patient. 

Must  go  to  bed  even  in  mildest  cases  on  account  of  danger  to  the 

kidneys,  and  cardio-vascular  apparatus. 
Bath. 

Soap  and  tepid  water  each  day.    Sponge  between  blankets,  or  in 

warm  room. 
Nightgown. 

Open  down  side  to  facilitate  examinations. 

Diet. 

For  general  principles  see  Chap.  II. 

For  details  of  diet  see  summary  of  Scarlet  Fever,  Chap.  XVII. 
Difficulties  of  feeding  accruing  from  angina  or  paralysis  are  met  by 
Feeding  by  gavage. 
500  c.c.  (1  pint)  of  milk. 


50  Gm.  (2  ounces)  sugar. 


Adult. 


1  egg. 

Give  three  times  a  day. 

Can  add  cream  to  above  mixture. 


DIPHTHERIA  479 

Technique  of  gavage. 

Adults,  use  stomach  tube. 

Children  over  three  years,  nasal  tube. 

Infants,  stomach  tube. 
Rectal  feeding. 

Less  satisfactory,  but  may  be  necessary. 
Nursing  infant. 

Take  from  mother's  breast. 

Feed  with  mother's  milk  obtained  by  pump  or  massage  to  assist 

with  wet  nurse's  milk  obtained  in  the  same  way. 
Water  should  be  given  freely  and  offered  every  hour  or  two. 
Fruit  juice  may  be  given  made  into  lemonade,  orangeade,  etc. 
An  insufficient  water  intake  because  of  painful  swallowing  is  to 

be  met  by 
Water  by  the  rectum  or  Murphy  drip. 

Care  of  mouth,  nose  and  genitals. 
(See  same  in  summary  under  Scarlet  Fever,  Chap.  XVII.) 

Bowels. 

(See  same  in  summary  of  Scarlet  Fever,  Chap.  XVII.) 

Dose. 

Determine  by 

1.  The  severity  of  the  disease. 

2.  The  day  of  the  disease  when  first  seen. 

3.  Somewhat  by  age  (Wright). 

In  mild  cases  (simple  congested  throat  with  positive  culture  or  one 

patch  on  one  tonsil) 

Give  3000-5000  units. 

Repeat  if  there  is  no  improvement  in  twelve  hours. 
In  more  severe  cases  (both  tonsils  involved) 

Give  5000^000  units. 
Repeat  in  six  hours  if  there  is  no  improvement,  and  repeat  at  six 

to  twelve  hour  intervals. 
In  still  more  severe  cases  (spreading  from  tonsils  onto  pillars  or 

pharynx) 

Give  8000  units,  intravenously. 
Repeat  at  six  to  twelve  hour  intervals. 
Toxic  cases. 

1.  If  a  pharyngeal  case  is  toxic. 

2.  If  there  are  laryngeal  manifestations,  hoarse  cry,  stridor  or 
laryngeal  cough. 

3.  If  in  addition  to  pharynx  nose  is  involved, 
Give  10,000  units,  intravenously. 
Repeat  dose  in  six  or  four  hours. 

Watch  continuously. 

In  malignant  cases  (rapid  spread,  marked  toxemia). 
Give  15,000-20,000  units  intravenously. 
Repeat  at  twelve,  six  or  four  hour  intervals. 


480  TREATMENT  OF  ACUTE  INFECTIOUS  DISEASES 

In  severe  or  laryngeal  cases  under  two  years 

Give  larger  doses;  three  days  ill,  three  times  the  ordinary  dose 
(Holt). 

Park  as  the  result  of  a  large  clinical  experience  and  from'  his  ex- 
perimental data  believes  a  single  dose  only  is  necessary,  and  that 
the  initial  dose  should  be  large. 

His  dosage  is  as  follows.  Units  in  case. 

Mild.  Moderate.  Severe.  Very  Severe. 

Infants  under  1  year 2,000  3,000  10,000          10,000 

Children  1  to  5  years 3,000  5,000  10,000          10,000 

Children  5  to  9  years 4,000  5,000  10,000          15,000 

Persons  over  10  years 5,000  10,000  10,000          20,000 

(For  New  York  Board  of  Health  dosage,  see  text.) 

Mode  of  administration. 
Subcutaneously. 
Blood  contents  of  antitoxin  reaches  maximum  between  third  and 

fourth  days. 
Intramuscularly. 

Somewhat  earlier. 
Intravenously. 
In  all  severe  cases. 

Blood  content  of  antitoxin  reaches  its  maximum  immediately. 
Technique  of  administration. 
Operator's  hands,  cleansed  with  soap  and  water,  then  alcohol  or 

1-1000  bichloride. 
Skin  of  patient  cleansed  with  soap  and  water,  then  alcohol  or 

paint  with  Tincture  of  Iodine. 
Boil  needle  and  a  small  length  of  rubber  tube  to  attach  needle  to 

syringe  and  prevent  breaking  of  needle,  if  child  struggles. 
Syringe,  boil.    Use  one  from  which  plunger  can  be  withdrawn  and 

allow  serum  to  be  passed  into  the  barrel. 
Expel  air  before  using. 
Antitoxin  usually  sent  in  a  syringe  as  a  container,  sterile  and 

ready  for  use. 
Site  of  injection. 

Loose  tissue  of  back  at  angle  of  scapula. 
Loose  tissue  of  abdominal  wall. 
Loose  tissue  of  anterior  chest  in  nipple  line  between  nipple  and 

costal  margin. 

Buttock,  especially  for  intramuscular. 
Basilic  vein  for  intravenous.    Compress  vein  lightly  above. 
Draw  a  drop  of  blood  to  prove  entrance  of  needle  into  vein,  before 
injecting. 

Evidences  of  improvement.     (See  text.) 

Disagreeable  and  dangerous  results  (anaphylaxis)  of  antitoxin  ad- 
ministration.   (See  text.) 


DIPHTHERIA  481 

Precautions. 

If  one  wishes  to  take  great  precautions  he  may  inject  one  or  two 
drops  at  first,  and  if  no  reaction  occurs  in  an  hour  give  the  rest. 

Precautions  in  asthmatics  should  always  be  taken. 

Use  concentrated  and  purified  antitoxin. 

Give  0.2  c.c.  for  first  dose. 

Repeat  in  an  hour. 

Give  0.4  c.c.  third  dose;  repeat  same  hourly  till  full  dose  is  attained. 

Give  atropine  sulphate,  gr.  1/100  (0.0006  Gm.)  at  the  start. 

Treatment  of  anaphylactic  shock. 

Atropine  sulphate gr.  1/50        (0.001  Gm.) 

Morphine  sulphate gr.  1/4          (0.015  Gm.) 

Adrenalin  (epinephrin)  1:1000. .  .m.  xv  (1  c.c.). 

Expelling  air  from  chest  by  brute  force. 

Immunizing  dose. 

Infants,  500  units. 
Children  and  adults,  1000  units. 
Repeat  at  intervals  of  ten  days  to  two  weeks. 
Precautions. 
Especially  asthmatics.    (See  above  under  summary.) 

Laryngeal  diphtheria. 

These  should  include  any  exposed  child  with  croupy  symptoms. 

Take  culture. 

Even  with  a  negative  culture  suspect  and  watch  closely. 

If  croup  persists  by  day  treat  as  true  diphtheria. 

Give  10,000  to  20,000  units  and  repeat  in  four,  six,  or  twelve  hours. 

Give  into  vein  always,  if  it  is  possible. 

Other  treatment.    Symptomatic. 
Inhalations. 
Steam,  using  croup  kettle  or  kindred  device.     (See  treatment  of 

Angina  in  summary  of  Scarlet  Fever.) 
Too  long  steaming  may  be  depressing. 
Hot  fomentations. 
Ice-bag  to  neck. 
Intubation.     \  /G  ,  >. 

Tracheotomy.  J  (S<*  text.) 

Fever. 

Rarely  demands  treatment. 

Sponge  baths  of  luke  warm  or  cool  water. 

Angina. 

Cold. 

Ice-bags  and  bladders. 

Ice-coil. 

Cold  compresses. 


482  TREATMENT  OF  ACUTE  INFECTIOUS  DISEASES 

Heat. 

Fomentations. 

Applications  to  throat. 
Irrigations. 

Salt  solution  3i  to  Oi  (4  Gm.  to  SCO  c.c.). 

Two  per  cent,  boric  acid  solution. 

Half  to  quarter  Dobell's  solution. 

Technique. 

Read  text  carefully. 
Sprays. 

Use  same  solutions  as  in  irrigation. 
Gargles. 

Painful  and  of  but  very  little  use. 
Avoid  astringents. 
Give  cracked  ice  to  suck. 
Pain  of  swallowing. 

Paint  with  1  per  cent,  to  2  per  cent,  cocaine  solution. 
Foul  mouth. 

1-2,000  potassium  permanganate  solution  before  the  bland  irriga- 
tion. 

Nasal  diphtheria. 

Irrigations.    Exercise  great  care  lest  ears  become  involved. 

Solutions  same  as  those  used  on  throat.    (See  Angina,  above.) 

Use  glass  nozzle  or  catheter  with  holes  cut  in  sides  and  an  irrigator 

or  fountain  syringe. 

Hold  just  high  enough  to  cause  a  gentle  flow. 

Frequency;  every  two  hours  in  severe  cases;  less  often  in  less  severe. 
Piston  syringe  may  be  used,  lacking  a  fountain  syringe. 
Patient  should  keep  mouth  open  during  the  procedure. 
Begin  first  on  the  side  most  obstructed. 
Swabs  and  sprays  if  irrigation  cannot  be  done. 
Use  same  solution. 

Hemorrhage  from  nose. 

Adrenalin  (epinephrin)  1-2000  or  1-3000  by  swab  on  applicator. 
Dry  packing. 

Packing  with  gauze  soaked  in  adrenalin  (epinephrin)  1-3000  up  to 
1-1000. 

Thromboplastin  and  coagulen.    (See  text.) 

Circulatory  failure. 

Early,  due  to  toxemia  as  in  other  infectious  diseases. 

Treat  as  in  circulatory  failure  in  Scarlet  Fever.    (See  Chap.  XVII.) 
Late. 

Prophylactic. 

Early  and  efficient  serum  treatment. 
Absolute  rest.    Sitting  up  in  bed  may  kill. 

Morphine  hypodermically,  every  four  hours  if  needed  to  keep 
patient  quiet. 


DIPHTHERIA  483 

Dose. 

Child  of  two  years,  gr.  1/48  (0.0015  Gm.). 
Child  of  six  years,  gr.  1/24-1/16  (0.0030-0.004  Gm.). 
Child  of  twelve  years,  gr.  1/12-1/8  (0.005-0.008  Gm.). 
Adult,  gr.  1/8-1/4  (0.008-0.015  Gm.). 
Stop  food  by  mouth. 
Feed  by  rectum. 
Reduce  all  procedures  about  the  patient  to  the  minimum  compatible 

with  needs. 

For  precordial  pain  and  distress. 
Heat  over  the  precordium. 
Drugs.    (See  text.) 


Caffeine. 

Camphor.  Strychnine. 

Digitalis.  Adrenalin. 

Strophanthin. 


See  their  use  under  Cir- 
culatory Failure  in  Scarlet 
Fever,  Summary  (Chap. 
XVII).  (See  text.) 


For  those  who  fear  the  effect  of  digitalis  on  the  vagus  in  inducing 
heart  block,  the  use  is  advised  of  atrppine  sulphate,  gr.  1/100 
(0.0006  Gm.)  with  each  dose  of  digitalis  or  strophanthin. 

For  collapse  or  syncopal  attack. 

Hot  saline  rectal  irrigations  at  110°  F.-1150  F. 

For  technique,  see  text. 
Hypodermoclysis  of  salt  solution  3i  in  Oi  (4  Gm.  in  500  c.c.)  at  100°  F. 

5viii-xvi  (240-500  c.c.). 

Cold  air. 

(For  the  technique  of  open-air  treatment;  see  Pneumonia,  Chap.  IX.) 

Paralyses. 

Preventive  measures. 

Early  and  efficient  serum  treatment. 

Absolute  rest  during  danger  period  up  to  fourth  week. 
(Rolleston  says  cardiac  and  palatal  paralyses  occur  in  first  two 

weeks.) 

Inform  the  patient  of  the  risk;  and  the  need  of  absolute  rest. 
Heart. 

(See  summary  under  circulatory  failure.) 
Palatal. 

Most  frequent  and  short  duration,  also  early. 
Feeding  by  gavage. 

Stomach  tube  in  infants  and  adults. 

Nasal  tube  in  children. 
Pharyngeal. 

Feeding  by  gavage. 
Respiratory. 

Lessen  weight  of  bedclothes. 

Avoid  positions  embarrassing  respiration  such  as  doubling  up. 

Raise  foot  of  bed  a  trifle  to  facilitate  discharge  of  secretions  from 
bronchi,  but  not  to  embarrass  respiration. 


484  TREATMENT  OF  ACUTE  INFECTIOUS  DISEASES 

Aspirate  food  particles  from  pharynx  with  rubber  catheter  and 

syringe. 
Swab  secretions  from  pharynx  with  cotton  on  dressing  forceps  or 

on  some  other  applicator. 

Occasional  compression  of  chest  to  help  expel  bronchial  secretions. 
Atropine  sulphate,  gr.  l/100^gr.  1/200  (0.0006-0.0003  Gm.)  accord- 
ing to  age  to  lessen  secretions. 
Give  three  or  four  times  a  day. 
Face  and  extremities  need  no  special  treatment. 
Nerve  tonic  and  stimulant  may  be  used. 
Strychnine  sulphate. 

Dose  for  child  of  two  years,  gr.  1/400-gr.  1/150  (0.00015-0.00045 

Gm.). 
At  twelve  years,  gr.  l/100-gr.l/40  (0.0006-0.0015  Gm.)  three  or 

four  times  a  day. 
Kidneys. 
The  urine  should  be  examined  each  day. 

Nephritis. 

Preventive. 

Early  and  efficient  serum  therapy. 

Treat  like  nephritis  in  Scarlet  Fever.     (See  Summary  of  Scarlet 

Fever,  Chap.  XVII.) 
Hot  packs  and  other  manipulations  causing  much  handling  are  not 

well  borne. 

Bronchopneumonia. 

Treated  like  any  other  bronchopneumonia.    (See  Chap.  IX.) 

Adenitis. 

(See  treatment  of  adenitis  in  Scarlet  Fever  Summary,  Chap.  XVII.) 

Otitis. 

(See  treatment  of  otitis  in  Scarlet  Fever  Summary,  Chap.  XVII.) 

Convalescence. 
Explain  to  the  parents  the  danger  to  the  heart  if  the  patient  is  allowed 

up  too  soon. 
Mild  cases. 

Flat  in  bed  until  end  of  third  week. 

Increase  number  of  pillows  two,  three,  four  and  five. 

Sit  up  in  bed  at  end  of  fourth  week. 

In  a  few  days  in  chair,  then 

In  a  few  days  allow  to  walk. 
Severe  cases. 

Six  or  eight  weeks  in  bed. 

In  no  case  allow  up  while  there  is  any  sign  of  heart  involvement. 
Food. 
Fresh  air. 


DIPHTHERIA  485 

Anaemia. 
Iron. 
Blaud's  pill   (Pil.  ferri   carbonatis),  gr.  ii-v  (0.15-0.30  Gm.)   three 

times  a  day. 
Vallet's  mass  (Massa  ferri  carbonatis),  gr.  ii-gr.  v  (0.015-0.30  Gm.) 

three  times  a  day. 
or 
Vinum  ferri  amarum  3i~ii  three  times  a  day  for  children. 

Tonics. 

Strychnine  sulphate. 
Dose  for  child  of  five  years,  gr.  1/200  (0.0003  Gm.)  three  times 

a  day. 
Dose  for  adult,  gr.  1/40-gr.  1/30  (0.0015-0.002  Gm.)  three  times  a 

day. 
Quinine. 

Doses  of  gr.  i  (0.06  Gm.)  three  times  a  day. 
May  combine  with  strychnine,  cod  liver  oil   (oleum  morrhuse) 
for  children  3ss.-i  (2-4  c.c.)  three  times  a  day. 

Release  from  quarantine. 

Three  negative  cultures  at  three-day  periods  should  be  obtained 

before  discharge. 
If  bacilli  persist 

Spray  with  bichloride  of  mercury  1-10,000  adding  glycerin  one  part 

in  eight  (Holt). 
(See  carriers,  below.) 

Bath  and  shampoo  with  warm  water  and  soap. 
Follow  with  bath  of  bichloride  1-5000. 

Sterilization  and  fumigation. 

(For  details  see  Scarlet  Fever  Summary,  Chap.  XVII.) 

For  method  of  fumigation  of  Maine  State  Board  of  Health  see  text. 

Funerals  should  be  private. 

Body  wrapped  in  strong  antiseptic  and  coffin  sealed. 

Carriers. 

Cats  and  dogs,  as  possible  carriers,  must  be  excluded  from  the  sick- 
room. 

Convalescents  released  without  culture  or  only  one  negative  culture 
are  possibly  carriers. 

Individuals  in  contact  with  the  patient  are  possibly  carriers  (50 
per  cent,  to  100  per  cent,  of  the  members  of  the  immediate  family 
were  found  to  be  carriers;  87  per  cent,  of  an  infected  school  were 
found  to  be  carriers). 

Bacilli  in  carriers  should  be  treated  for  virulency  to  determine  the 
danger  entailed  by  an  individual  to  his  environment. 

Deep  crypts  of  tonsils  as  well  as  the  surface  should  be  examined. 


486  TREATMENT  OF  ACUTE  INFECTIOUS  DISEASES 

Cultures  should  be  taken  from  nose  and  naso-pharynx. 
Nose  and  accessory  sinuses  inspected  for  abnormalities  and  infections 
that  favor  the  carrier  condition. 

Treatment. 
Non-operative: 

Sprays  of  all  kinds  proved  inefficient. 

Spraying  the  throat  every  two  hours  with  a  virulent  culture  sta- 
phylococcus  and  an  occasional  swabbing  with  the  same.     Use 
of  antitoxin  does  not  affect  the  organisms. 
Operative: 

Correction  of  abnormalities. 
Diseased  tonsils,  adenoids,  removed. 
Accessory  sinus  disease  treated. 


CHAPTER  XIX 

MEASLES 

MEASLES  is  a  disease  affecting  individuals  of  all  ages,  but  particu- 
larly those  in  the  first  five  years  of  life. 

All  children  are  highly  susceptible.  The  only  exception  to  this  is  in 
the  first  five  or  six  months  of  life,  during  which  the  chances  of  escape  in 
an  epidemic  are  relatively  good. 

Measles  is  a  serious  disease,  a  fact  not  sufficiently  appreciated  by  the 
laity  and  often  overlooked  by  the  profession. 

In  adults  the  occasional  case  of  measles  impressed  us  but  little  as  a 
serious  disease,  though  we  were  familiar  with  the  history  of  its  ravages 
among  savage  people  when  first  introduced,  but  the  epidemic  of  measles 
that  invaded  our  camps  during  the  late  war  gave  it  a  new  and  alarming 
significance. 

What  the  etiological  agent  in  this  disease  is,  we  do  not  know,  but 
Hektoen  declares  it  to  be  present  in  the  nasal  secretions,  in  the  blood,  and 
in  scrapings  from  the  skin  in  the  early  eruptive  period. 

The  mortality  among  infants  and  delicate  children  is  very  high, 
15  per  cent,  to  35  per  cent,  in  institutions,  4  per  cent,  to  6  per  cent,  at 
home  under  better  environment  (Holt),  and  while  the  mortality  is  low 
among  older  children  and  adults,  complications  such  as  pneumonia  and 
ear  involvement  may  be  highly  dangerous  or  fatal,  while  the  suscepti- 
bility to  tuberculous  invasion  is  greatly  enhanced. 

The  mortality  in  camps  complicated  by  streptococcic  infection  exag- 
gerated naturally  its  menace  in  civil  life  but  emphasizes  the  warning  not 
to  consider  measles  a  trivial  disease. 

No  more  pernicious  teaching  can  be  imagined  than  that  as  a  child 
will  probably  have  measles  some  time,  the  sooner  it  is  exposed  and  has 
it  the  better.  The  older  the  child  is,  other  things  being  equal,  the  better 
will  it  withstand  the  disease  and  its  complications. 

It  is  not  the  measles,  per  se,  that  affords  the  danger,  but  the  fact 
that  it  reduces  the  resistance  of  the  mucous  membranes  of  the  respiratory 
tract  to  the  onslaughts  of  the  pyogenic  organisms,  the  staphylococci, 
the  streptococci  and  the  pneumococci,  and,  as  has  been  said,  renders 
the  soil  fertile  for  the  tubercle  bacillus. 

The  incubation  lasts  from  10  to  14  days;  it  is  highly  infectious  from 
the  appearance  of  the  first  symptom;  hence,  precedes  the  diagnostic 


488  TREATMENT  OF  ACUTE  INFECTIOUS  DISEASES 

rash  by  several  days  and  facilitates  the  spread  of  the  infection.  It  is  the 
secretions  of  the  nose  and  eyes  that  are  especially  contagious  and  the 
infectivity  disappears  with  the  catarrhal  discharges  and  so  is  short  lived. 
It  is  not  air  borne,  but  coughing  and  sneezing  can  convey  it  over  con- 
siderable distances.  A  third  person  coming  directly  from  a  case  can 
convey  the  disease,  but  the  virus  is  readily  killed  and  is  rarely  conveyed 
by  the  third  person,  the  physician  or  other,  as  is  the  case  with  scarlet 
fever. 

Distribution  of  the  Family.  Every  child  directly  exposed,  ex- 
cept very  young  infants,  are  almost  certain  to  become  infected.  The 
chances  of  escaping  are  not  comparable  to  those  exposed  to  scarlet 
fever.  The  young  infant,  being  less  susceptible,  is  still  capable  of  ac- 
quiring the  disease  and  as  the  mortality  is  high  in  this  group  of  patients, 
every  effort  to  avoid  the  infection  should  be  taken.  The  child  should 
be  removed  to  another  house  until  the  period  of  incubation  of  measles 
has  passed.  The  chances  of  isolation  in  the  same  house  are  almost  nil 
in  contrast  to  the  partial  success  of  such  attempts  in  scarlet  fever. 
Absolute  isolation  of  all  in  contact  with  the  patient  is  necessary  for 
success. 

It  cannot  be  too  emphatically  insisted  that  no  person  having  a  cold, 
sore  throat  or  infection  of  the  upper  air  passages  should  come  in  contact 
with  the  patient  lest  he  be  a  carrier  of  streptococcus  and  hence  a  real 
danger  to  the  patient. 

Whether  another  house  shall  be  exposed  to  the  almost  certain  infec- 
tion by  removal  to  it  of  the  other  older  children  of  the  family  is  a  ques- 
tion, but  as  the  infection  does  not  cling  to  the  house  and  room,  as  in 
scarlet  fever,  I  feel  that  inconvenience  should  not  be  set  against  a  chance 
in  behalf  of  any  child. 

Quarantine  for  such  children  may  be  broken  at  the  end  of  two  weeks, 
if  there  are  no  catarrhal  signs,  no  Koplik's  spots  and  no  temperature. 
Three  weeks  would  meet  the  demands  of  great  precaution.  Of  course, 
all  children  in  the  infected  household  should  be  excluded  from  school 
until  the  patient  is  convalescent  and  the  period  of  incubation  for  those 
who  have  not  had  the  disease  is  passed. 

Room.  Fear  for  the  eyes  and  for  the  lungs  has  condemned  the 
patient  traditionally  to  darkness  and  to  a  room  deprived  of  air.  This 
tradition  even  the  profession  has  had  great  difficulty  in  disregarding  and 
in  no  illness  is  the  room  more  devoid  of  cheer  and  comfort  than  in 
measles. 

Light  is  a  most  potent  ally  in  combating  infection  and  air  is  not  only 
necessary  to  life,  but  is  a  most  valuable  therapeutic  agent. 

If  an  attempt  at  isolation  is  to  be  made,  the  choice  and  manage- 


MEASLES  489 

ment  of  the  room  must  be  identical  with  that  demanded  in  a  scarlet 
fever  case.  (See  Scarlet  Fever,  Chap.  XVII.) 

It  is  true  that  the  eyes  have  to  be  considered  in  the  treatment  of 
measles  and  a  glaring  light  direct  in  the  eyes  is  to  be  avoided ;  this  may 
be  done  by  placing  the  bed  or  moving  the  bed  from  time  to  time  to  avoid 
it,  by  letting  the  eyes  rest  on  a  darker  surface,  such  as  a  hanging  of  green 
material,  by  a  screen  or  by  the  use  of  colored  glasses.  At  the  most  the 
room  should  be  slightly  darkened.  The  degree  of  comfort  or  discomfort 
of  the  patient  is  really  the  best  regulator  of  the  quantity  of  light. 

Of  air  there  can  never  be  too  much.  Draughts  are,  of  course,  to 
be  avoided.  The  temperature  is  to  be  kept  at  65°  F.  or  70°  F.,  but 
in  a  toxic  condition  a  colder  air  is  highly  beneficial,  provided  the  body  is 
well  protected.  If  the  cough  is  severe  a  degree  of  moisture,  obtained  by 
the  use  of  croup  kettles  or  other  generators  of  steam  may  alleviate  it, 
but  the  air  is  not  to  be  rendered  heavy  with  moisture.  Clear  cold  air 
will  often  prove  more  efficacious;  patients  react  differently  to  these 
measures. 

When  conditions  permit  of  it,  two  adjoining  rooms  may  be  devoted  to 
the  patient,  thus  giving  the  opportunity  for  a  thorough  ventilation  and 
exposure  to  bright  sunlight  to  the  room  for  the  time  unoccupied. 

Two  children  sick  of  measles  should  never  be  treated  in  the  same 
room,  lest  complicating  diseases  like  pneumonia  be  transmitted. 

In  hospitals  and  institutions,  if  separate  rooms  cannot  be  secured  the 
patients  should  lie  in  separate  cubicles.  These  I  saw  in  operation  years 
ago  in  Grancher's  clinic  at  L'hospital  des  Enfants  Malades  in  Paris. 
They  reminded  me  of  horse  stalls,  the  partitions  being  of  glass,  3  to  4  feet 
high  raised  from  the  floor  to  allow  the  air  to  circulate.  The  glass  afforded 
the  nurse  in  charge  an  uninterrupted  view  down  the  ward.  In  our  camps 
gauze  screens  were  used  and  are  readily  adaptible  to  an  emergency. 

The  Nurse.  When  isolation  is  carried  out  with  a  view  of  pro- 
tecting other  children  of  the  family,  the  nurse  should  be  as  carefully 
restricted  to  the  sick-room  and  her  own  room  as  in  scarlet  fever.  When 
there  are  no  other  children  in  the  family,  such  restrictions  are  hardly 
necessary.  She  should,  however,  have  no  direct  contact  with  adult 
members  who  have  never  had  the  disease. 

Again,  in  her  outings,  she  should  keep  away  from  children,  but  need 
observe  no  such  precautions  as  if  on  a  scarlet  fever  or  diphtheria  case. 

If  the  nurse  has  recently  been  in  contact  with  an  acute  infectious 
case,  it  would  be  wise  to  determine  whether  or  no  she  was  a  carrier 
of  streptococcus  hemolyticus.  If  she  has  more  than  one  child  in  charge 
in  a  family,  she  should  wear  a  gauze  mask  to  prevent  her  acting  as  a 
carrier,  having  a  mask  for  each  room.  She  should  also  wear  a  gown. 


490  TREATMENT  OF  ACUTE  INFECTIOUS  DISEASES 

The  Physician.  The  rarity  with  which  this  disease  is  trans- 
mitted through  the  third  person  makes  the  extraordinary  precautions 
exercised  by  the  physician  when  on  a  scarlet  fever  case  unnecessary, 
particularly  if  he  is  for  a  time  in  the  open  air  after  a  visit  and  does  not 
go  directly  from  a  measles  case  to  another  child. 

He  should,  however,  wear  a  gown  in  the  sick-room  and  cleanse  his 
hands  with  soap  and  water  and  alcohol  or  other  antiseptic  before  leaving. 

Wearing  a  mask  in  the  sick-room  will  help  to  prevent  his  acting  as 
a  carrier. 

Precautions  in  the  Sick-Room.  While  the  virus  is  far  less 
persistent  than  that  of  scarlet  fever  and  diphtheria  and  so  the  danger 
of  .transmission  less,  one  ought  to  observe  the  same  precautions  with 
reference  to  the  infectious  material  contaminating  the  articles  in  use 
by  the  patient  as  in  these  other  conditions.  This  will  be  found  in  detail 
under  Scarlet  Fever. 

When  there  are  no  children  in  the  house  and  isolation  is  not  carefully 
observed,  the  soaking  of  the  clothes  in  disinfectants  before  going  to  the 
wash,  if  that  is  done  at  home,  need  not  be  carried  out. 

Bed.  For  the  proper  kind  of  bed  and  the  preparation  see  Scar- 
let Fever,  Chap.  IX.  The  covering  should  be  light  unless  cold  air  is 
admitted  to  the  room,  just  enough  to  afford  the  patient  comfort. 

PATIENT 

Nightgown.  Should  be  of  linen  or  cotton,  unless  cold  air  is 
admitted  to  the  room,  or  draughts  cannot  be  avoided;  then  the  flannel 
nightgown  is  to  be  preferred.  It  should  be  open  down  the  front  so  that 
the  chest  can  be  readily  exposed  for  examination. 

Bath.  Great  fear  seems  to  be  entertained,  by  many  physicians,  of  the 
bath.  I  cannot  see  any  danger,  but  much  good,  in  a  cleansing  bath  of 
soap  and  water  with  the  sponge.  If  the  patient  is  exposed,  the  room 
should  be  previously  warmed  to  a  little  over  70°  F.  If  concern  is  excited 
by  this  hygienic  procedure,  the  patient  may  be  put  between  blankets 
and  one  part  after  the  other  exposed  and  bathed  or  the  patient  may  be 
sponged  under  the  blanket.  Not  only  does  it  keep  the  skin  clean  and 
assist  the  inflamed  structure  in  its  normal  functions,  but  it  is  decidedly 
refreshing  to  the  patient.  The  bath  water  should  be  lukewarm  or  cool. 

Diet.  The  energy  demands  of  the  body  continue  during  an  in- 
fection as  in  health;  for  a  man  at  rest,  indeed,  the  demands  during  fever 
are  greater,  because  of  certain  additional  demands  made  by  the  pyrexia, 
per  se,  and  by  the  destruction  worked  by  the  toxins  of  the  disease. 

The  derangement  of  the  functions  of  the  alimentary  canal  during 


MEASLES  491 

a  prolonged  and  severe  infection  is  remarkably  little  (see  Diet  in  Acute 
Infectious  Disease,  Chap.  II),  but  such  as  there  is  is  more  marked  at  the 
incipiency  of  the  infection.  In  short  acute  infections,  then,  there  is  no 
necessity  for  urging  food  to  meet  theoretical  demands,  both  because  of 
the  temporary  derangement  of  alimentation  and  because  of  the  brief 
period  of  the  infection.  At  such  a  time  anorexia  should  be  respected  as 
of  conservative  significance.  When,  however,  the  infection  is  prolonged 
in  its  regular  course,  or  prolonged  because  of  added,  that  is,  mixed  infec- 
tion, the  necessity  for  supplying  enough  food  becomes  of  great  moment. 

Measles  runs  a  short  febrile  course  and  the  amount  of  food  can  be  left 
to  the  patient's  inclination ;  but  if  complicated  by  a  bronchopneumonia, 
continuing  for  some  time,  the  caloric  and  protein  needs  must  be  reckoned. 

In  young  infants  on  the  bottle,  the  food  should  be  diluted  with  water 
or  thin  cereal  water  one-half  or  one-quarter. 

In  older  infants  the  milk  had  better.be  diluted. 

In  older  children  and  adults,  milk  and  gruels  made  of  arrowroot, 
barley,  wheat  flour,  cornstarch,  farina  or  imperial  granum  or  small 
quantities  of  the  cereals  themselves  with  milk  or  cream  and  sugar, 
jellies  of  barley,  tapioca  and  sago,  boiled  rice,  milk  toast;  or  some  of  the 
other  modifications  of  milk  such  as  buttermilk,  koumys,  matzoon, 
afford  variety.  If  the  fever  continues,  add  bread  and  butter,  eggs, 
custard,  scraped  beef,  vegetable  soups.  As  the  fever  becomes  normal, 
add  small  quantities  of  scraped  beef,  raw  oysters,  chicken  or  squab, 
finely  minced.  The  additions  are  made  in  convalescence  of  the  shorter 
attacks. 

For  the  caloric  values  of  articles  here  mentioned,  see  Scarlet  Fever, 
Chap,  XVII. 

Water  is  to  be  administered  freely.  It  is  to  be  given  whenever 
asked  for,  but  it  is  also  to  be  offered  during  each  waking  hour.  Plain 
or  alkaline  waters,  lemonade,  orangeade,  imperial  drink,  may  be  used. 
The  latter  may  be  sweetened  freely,  every  ounce  of  sugar  adding  120 
calories  of  food. 

The  administration  of  water  is  too  often  neglected,  while  it  is  infinitely 
more  important  than  many  drugs,  the  intervals  of  whose  administration 
is  jealously  observed  by  physician  and  nurse. 

Skin.  A  warm  cleansing  bath  is  given  each  day  and  a  second 
may  be  given  if  it  adds  to  the  patient's  comfort. 

Often  there  is  a  good  deal  of  itching  and  burning.  This  may  be  re- 
lieved by  sponging  with  a  solution  of  sodium  bicarbonate,  3i  to  3  pints 
(4  Gm.  to  1,500  c.c.)  of  water  or  dabbing  on  bran  water,  made  by  putting 
a  handful  of  bran  in  a  muslin  or  cheesecloth  bag  and  moving  this  about 
in  a  gallon  (4  liters)  of  water  until  it  becomes  milky.  For  more  severe 


492  TREATMENT  OF  ACUTE  INFECTIOUS  DISEASES 

itching  1  per  cent,  to  2  per  cent,  carbolic  acid  (phenol)  in  oil  or  vaseline 
may  be  used. 

When  desquamation  begins  the  body  may  be  anointed  with  vaseline 
after  the  daily  bath.1 

V 

Phenolis gtt.  xx-xl  (1 . 3-2 . 6  c.c.) 

Pulv.  Zinci  Oxidi 

Pulv.  Amyli , 

Pulv.  Calaminae aa  3ii  (8  Gm.) 

Glycerini 5ij  (8  c.c.) 

Aq.  Calcis q.  s.  ad. . .  3  iv        (120  c.c.) 

M.   Mop  on  or  apply  cloths  wet  with  the  solution.    Do  not  rub. 

Mouth.  When  one  considers  that  the  most  common  and  serious 
complications  of  measles  is  due  to  the  presence  in  the  mouth  of  pyogenic 
organisms,  the  staphylococci,  streptococci  and  pneumococci,  which  have 
invaded  the  air  passages  to  the  production  of  bronchitis  and  broncho- 
pneumonia,  one  appreciates  the  importance  of  measures  aimed  at  keep- 
ing the  mouth  and  nose  clean. 

After  each  meal  the  mouth  should  be  rinsed  with  normal  salt  solu- 
tion (3i  to  the  pint)  (4  c.c.-500  c.c.)  or  2  per  cent,  to  4  per  cent,  boric 
acid  solution  of  1/2  or  1/4  strength  Dobell's  solution.  Swabs  on  wooden 
tooth-picks,  saturated  with  the  same  solutions,  should  be  used  to  cleanse 
the  teeth  and  the  spaces  between  the  teeth  and  cheeks  or  lips.  For 
sordes  or  coated  tongue,  half  strength  solution  of  hydrogen  dioxide, 
peroxide  of  hydrogen  (official)  may  be  applied  first,  the  tongue  gently 
scraped  with  the  edge  of  a  whale-bone  and  the  solutions  mentioned 
then  used. 

If  the  mouth  is  dry  equal  parts  of  2  per  cent,  boric  acid  and  liquid 
petrolatum  with  a  little  lemon  juice  affords  a  pleasing  application. 

Sprays  of  the  same  solutions  should  be  used  for  the  throat.  Gargles 
are  not  efficacious  for  this  purpose. 

Nose.  Dried  secretions  should  be  moistened  with  sweet  oil  and 
then  cleansed  with  the  same  solutions  as  the  mouth.  The  swab  on 
the  tooth-pick  may  be  used  for  these  purposes.  Sprays  of  the  same 
materials  should  follow. 

Eyes.  The  eyes  should  be  cleansed  twice  a  day,  or  oftener,  if  needed, 
with  saturated  boric  acid  solution.  Vaseline  may  be  smeared  on  the 
edges  of  the  lids  to  prevent  gluing.  One  drop  of  20  per  cent,  solution  of 
argyrol  in  each  eye  every  two  hours  from  the  beginning  of  conjunctivitis 
until  it  clears  up  is  an  excellent  procedure.  (Bingham.) 

1Hubbard  recommends  for  itching,  if  much  surface  is  involved,  the  pre- 
scription cited. 


MEASLES  493 

The  genitals  should  be  attended  to  and  kept  free  from  irritating 
secretions,  using  the  saline  or  boric  acid  solutions. 

Bowels.  When  first  seen  a  free  catharsis  should  be  given.  To  the 
infant  or  very  young  child,  castor  oil,  3i  to  oii  (4-8  c.c.)  or  calomel, 
gr.  1/10  to  gr.  1/4  (0.006-0.015  Gm.)  at  10  to  15  minute  intervals  until 
1  grain  (0.060  Gm.)  is  taken.  In  older  children  and  adults,  a  salt,  Epsom, 
Rochelle,  Glauber's,  or  Sodium  phosphate  in  doses  of  3ii  to  iv  (8-15  Gm.) 
in  1/2  glass  of  water,  alone  or  preceded  by  calomel  gr.  i  to  gr.  iss.  (0.060- 
0.10  Gm.)  in  divided  doses. 

To  children  Liquor  Magnesii  Citratis  3vi  to  viii  (180-240  c.c.)  is  more 
grateful  or  milk  of  magnesia  3ss.  (15  c.c.)  following  the  calomel. 

The  bowels  should  be  moved  by  an  enema  or  Liq.  Mag.  Cit.  or 
Hunyadi  water  at  least  every  other  day. 

Fever.  A  moderate  degree  of  fever,  that  is  104°  F.  or  below  is  to 
be  let  alone  or  even  105.5°  F.  if  only  for  a  few  hours.  As  a  rule  measles 
is  not  accompanied  by  greater  degrees  of  fever  than  these  mentioned  and 
the  course  is  short.  When,  however,  a  sudden  impulse  of  temperature 
to  106°  F.  or  above  occurs  or  a  temperature  of  104°  F.  to  105°  F.  persists, 
an  effort  should  be  made  to  reduce  it.  Craster  has  shown  that  the  liabil- 
ity to  a  fatal  issue  increases  directly  as  the  temperature. 

Drugs  should  not  be  used  for  this  purpose.  Nothing  equals  cold 
water  as  an  antipyretic. 

For  young  infants  sponging  is  the  best,  for  children  the  pack  or  sponge 
and  for  older  children  and  adults  the  pack  or  bath. 

The  younger  the  child,  the  warmer  the  water  used.  Baths  for  children 
should  be  graduated.  The  water  used  in  these  procedures  should  begin 
at  95°  F.  to  98°  F.  and  be  gradually  reduced  to  85°  F.  or  lower,  depending 
on  the  reaction  of  the  patient  and  the  fall  in  temperature.  One  should 
be  satisfied  with  a  fall  to  102°  F.  and  at  this  point  intermit  the  procedure. 
Ice  to  the  head  adds  to  the  efficacy  of  the  other  measures. 

If  there  is  any  sign  of  collapse  during  the  bath,  one  should  take  the 
patient  out,  wrap  him  in  warm  blankets,  put  heat  to  the  extremities 
and  give  warm  drinks. 

If  with  a  high  temperature  the  extremities  are  cold,  the  patient's 
color  poor  and  pulse  small,  the  hot  mustard  bath  should  be  given  with 
ice  applied  to  the  head. 

The  mustard  bath  is  made  by  using  mustard  in  the  proportion  of  a 
tablespoonful  to  the  gallon.  Put  the  mustard  into  a  small  part  of  the 
water  at  a  tepid  temperature  to  cause  the  formation  of  the  oil  from  the 
mustard,  then  add  the  rest  of  the  water,  in  a  few  minutes  bringing  it  up 
to  the  temperature  of  100°  F.  After  the  child  is  immersed  to  the  neck, 
warmer  water  to  bring  the  whole  to  105°  F.  can  be  added  if  desired.  The 


494  TREATMENT  OF  ACUTE  INFECTIOUS  DISEASES 

child  may  be  left  in  five  to  ten  minutes,  then  dabbed  dry,  rolled  in  a 
warm  blanket,  with  heat  at  the  feet  and  ice  at  the  head. 

Cardio- Vascular.  Except  in  the  rare  instances  of  malignant 
measles  and  in  bronchopneumonia  as  a  complication,  the  heart  does 
not  demand  serious  attention.  When,  however,  the  circulation  fails 
in  this  condition,  the  same  causes  may  be  deemed  operative  as  in  other 
acute  infections,  and  the  same  measures  should  be  undertaken  to  combat 
it.  These  are  dealt  with  at  length  under  scarlet  fever.  In  no  way  is  the 
treatment  modified  because  the  infection  is  measles  instead  of  scarlet 
fever. 

As  most  of  the  cases  are  infants  or  young  children,  the  doses  should 
be  suitable  for  them. 

Digitalis  and  strophanthin  are  the  only  reliable  drugs.  Eggleston's 
rule  of  2  minims  of  tincture  of  digitalis  per  pound  of  patient  to  accom- 
plish digitalization  is  applicable;  e.  g.,  a  child  of  30  pounds  would  call  for 
60  minims  of  tincture  or  6  grains  of  digitalis.  This  should  be  adminis- 
tered in  36  hours.  One  would  give  10  minims  every  6  hours  or  in  more 
urgent  cases  20  minims;  for  the  first  dose  strophanthin  might  be  used, 
1/10-1/5  of  a  milligram. 

The  digitalis  must  be  known  to  be  fresh  and  of  guaranteed  assay 
and  it  must  be  remembered  that  a  minim  of  tincture  is  not  a  drop. 
Always  measure  the  digitalis  in  a  minim  glass. 

The  above  dosage  is  a  guide  but  the  dose  must  be  modified  to  attain 
results.  (See  Pneumonia,  Chap.  IX.) 

Caffeine  gr.  1/8,  1/4,  or  1/2  (0.008-0.015-0.030  Gm.)  in  the  form  of 
one  of  the  soluble  double  salts  of  salicylate  or  benzoate  every  two  or  three 
hours,  camphor,  gr.  1/5  to  gr.  1/2  (0.012-0.030  Gm.)  in  oil  10  per  cent., 
adrenalin  (epinephrin)  1  to  1000  for  sudden  collapse,  m.  ii  to  m.  v 
(0.150-0.33  c.c.)  into  a  muscle,  may  be  tried  with  less  anticipation  of 
results  than  from  the  digitalis  bodies  or  may  be  used  if  digitalis  fails. 

For  respiratory  failure  these  same  drugs  and  atropine  sulphate  gr. 
1/400  (0.00015  Gm.) 

Nervous  Symptoms.  In  the  severe  cases  the  cerebral  mani- 
festations may  be  pronounced;  restlessness  to  delirium  and  even  con- 
vulsions or  there  may  be  stupor. 

These  expressions  of  toxemia  in  the  cortex  of  the  brain  are  to  be  com- 
bated like  those  impinging  on  the  vaso-motor  and  respiratory  centers 
at  the  base,  by  the  use  of  hydrotherapy. 

The  warm  sponges  and  baths  for  sedative  effects  and  the  colder 
ones  for  stimulating.  These  baths,  sponges  and  packs  are  to  be  used 
as  described  under  the  section  on  Fever. 

An  ice  cap  to  the  head  has  a  quieting  effect. 


MEASLES  495 

If  these  measures  are  not  efficacious  or  not  attainable  and  drugs 
must  be  used,  in  very  young  children  antipyrin  in  doses  of  1  grain  (0.060 
Gm.)  and  sodium  bromide  in  doses  of  gr.  iii  to  gr.  iv  (0.20-0.25  Gm.) 
three  or  four  times  a  day  may  be  tried.  In  older  children  of  five  or  six, 
bromide  in  doses  of  gr.  v  (0.30  Gm.)  three  or  four  times  a  day,  in  adult 
gr.  xv  to  gr.  xx  (1-1.30  Gm.)  at  the  same  intervals.  Acetphenetidin 
(phenacetin)  in  doses  of  gr.  i  to  gr.  ii  (0.060-0.125  Gm.)  to  young  children 
may  prove  sedative,  repeated  as  with  the  others. 

For  sleeplessness  in  children,  the  baths  and  the  small  doses  of  bro- 
mides and  antipyretics  mentioned  are  the  best. 

In  adults  trional,  sulphonethylmethane  in  gr.  x  (0.60  Gm.)  doses  and 
chloralamid  in  doses  of  gr.  xx  (1.30  Gm.)  may  be  used  and  repeated  in 
two  or  three  hours  if  needed. 

For  wild  delirium,  sacrificing  sleep  and  rest,  morphine  will  be  neces- 
sary, hypodermically,  gr.  1/4  (0.015  Gm.)  in  the  adult,  gr.  1/16  (0.004 
Gm.)  in  the  older  children,  gr.  1/24,  to  gr.  1/48  (0.003-0.0015  Gm.)  in 
the  younger. 

COMPLICATIONS 

Bronchopneumonia.  Of  the  serious  complications  of  measles 
bronchopneumonia  is  far  and  away  the  most  common  and  is  responsible 
for  the  great  majority  of  the  fatal  cases. 

In  private  practice  the  incidence  of  pneumonia  is  given  at  about 
10  per  cent.,  but  is  much  more  common  in  institutions.  The  mortality 
is  very  much  higher,  too,  in  hospitals  than  in  private  practice.  In  the 
hospital  a  child  with  pneumonia  should  be  promptly  removed  from  the 
environment  of  the  simple  cases,  as  the  condition  will  spread  readily 
among  the  cases.  An  abundance  of  air,  close  attention  to  the  toilet  of 
the  mouth  and  avoidance  of  exposure  of  the  body  to  draughts  and  chilling 
are  prophylactic  measures. 

Most  of  the  cases  occur  in  the  first  five  years  of  life  and  the  mortality 
is  many  times  higher  in  infants  under  two  than  in  the  older  children  of 
the  first  lustrum. 

The  appearance  of  bronchopneumonia  in  a  case  of  measles  changes  the 
whole  aspect  of  the  case.  The  treatment  henceforth  is  that  of  pneumo- 
nia, modified  not  at  all  by  the  fact  that  it  complicates  measles. 

During  the  late  war  measles  in  camps  was  so  complicated  by  strep- 
tococcus hemolyticus  that  it  modified  the  picture  of  pneumonia  cases  to 
no  inconsiderable  extent  and  was  accompanied  by  a  high  per  cent,  of 
empyema  and  other  streptococcic  lesions.  For  discussion  of  these  cases 
see  streptococcic  pneumonia  (Chap.  X). 


496  TREATMENT  OF  ACUTE  INFECTIOUS  DISEASES 

The  patient'must  be  kept  in  bed,  unless  a  young  infant,  when  it  may 
be  taken  up  from  time  to  time.  The  older  patients  in  bed  must  be  turned 
from  time  to  time  to  avoid  hypostasis  and  encourage  the  discharge 
of  secretions.  The  temperature  of  the  room  should  be  kept  from  65°  F. 
to  70°  F.  unless  the  cold  air  treatment  is  instituted  when  especial  provi- 
sion in  making  the  bed  should  be  made.  As  the  temperature  is  more 
sustained  and  as  an  additional  toxemia  must  be  combated,  more  fre- 
quent sponging  adds  to  the  comfort  and  refreshes  the  patient.  The  care 
of  the  mouth  must  be  carried  out  more  rigidly  than  ever  and  if  the 
breath  is  foul  or  there  is  stomatitis  a  phenol  solution  such  as  the  following 
should  be  applied: 


Phenol  (Watery  solution  1-20) 

Boric  Acid  (sat.  watery  sol.) aa  3i  (30  c.c.) 

Glycerin 5  viii          (240  c.c.) 

M. 

The  diet  should  be  more  liberal  than  at  the  beginning,  to  meet  the 
caloric  needs,  adding  at  least  25  per  cent,  to  the  requirements  in  health. 
(See  Scarlet  Fever,  Chap.  XVII,  for  the  caloric  requirements.) 

The  importance  of  the  ingestion  of  a  sufficiency  of  water  must  be 
emphasized,  offering  it  every  hour. 

Open  Air  Treatment.  A  considerable  experience  with  this  mode 
of  treatment  has  made  me  an  enthusiastic  advocate  of  it.  The  results 
are  so  striking  and  so  satisfactory  that  it  is  tragic  that  the  physician  who 
is  convinced  is  so  handicapped  by  the  traditional  fear  of  the  cold  enter- 
tained so  largely  by  the  laity.  The  most  enthusiastic  party  concerned  is 
the  patient.  It  must  be  emphasized,  however,  that  the  technique  must 
be  correct  and  carefully  carried  out.  Precise  instructions  about  the 
making  of  the  bed,  the  protection  of  the  patient,  the  watchfulness  of  the 
nurse,  must  be  given.  Detail  is  set  forth  in  the  article  on  Pneumonia, 
Chap.  IX. 

Improvement  is  seen  in  the  lessening  of  the  nervous  symptoms, 
better  sleep,  improved  appetite,  better  pulse  and  respiration. 

Objections  are  made  to  the  cold  air  treatment  in  the  case  of  very 
young  and  delicate  children  and  in  cases  of  capillary  bronchitis.  Cer- 
tainly, watchfulness  must  be  more  vigilant  in  these  cases.  As  for  the 
capillary  bronchitis,  some  react  exceedingly  well  to  the  open  air  treat- 
ment, while  others  do  not  do  so  well.  The  response  of  the  individual 
case  must  be  studied. 

Next  in  value  to  the  cold  air  in  the  combat  with  toxemia  is  cold 
water.  It  may  be  applied  in  the  shape  of  cold  chest  compresses,  cold 


MEASLES  497 

sponging,  the  graduate  bath,  beginning  at  95°  F.  and  reducing  to  85°  F. 
or  the  evaporation  bath. 

In  the  early  stages  mustard  paste,  one  part  of  mustard  to  five  or  six 
of  flour  in  infants  and  one  in  four  in  older  children,  depending  more 
or  less  on  the  reaction  of  the  skin,  may  be  applied.  These  may  be  applied 
every  4,  6  or  8  hours.  (See  Pneumonia,  Chap.  IX.)  Poultices  and 
jackets  add  weight  and  are  of  little  value. 

Fever.  Continuous  high  temperature  is  exhausting.  Its  effects 
are  to  be  met  by  frequent  sponging  with  tepid  water,  or,  if  the  degree 
of  toxemia  is  marked  with  the  colder  applications,  sponges,  packs 
or  baths. 

Hyperpyrexia  calls  for  extraction  of  heat,  as  explained  in  the 
preceding  section  on  fever. 

Cough.  This  is  likely  to  be  severe  in  the  cases  with  much  bron- 
chitis. In  some  the  effects  of  the  open  air  is  highly  satisfactory,  in 
others  the  applications  of  the  chest  compress,  but  many  show  an  in- 
crease of  the  cough  or  a  "tightening"  of  the  breathing,  that  finds  relief 
in  a  warmer,  moisture  laden  air.  The  effects  of  steam  from  a  croup 
kettle  in  a  tent  made  with  a  sheet  over  the  upper  part  of  the  crib,  or  over 
a  clothes  horse  or  screen  often  has  a  happy  effect.  If  the  results  of  the 
plain  steam  are  not  satisfactory,  compound  tincture  of  benzoin,  or 
creosote  may  be  added,  a  teaspoonful  upon  the  water  of  the  kettle.  A 
degree  of  moisture  may  be  obtained  by  water  heated  in  shallow  dishes 
elsewhere  in  the  room.  It  is  not  desirable  to  load  the  atmosphere  of  the 
room  with  steam.  It  and  the  heat  generated  are  depressing,  nor  should 
the  child  be  kept  too  long  under  the  tent.  The  room  should  be  thor- 
oughly aired  two  or  three  times  a  day,  the  child  being  removed  to  an 
adjoining  room  during  the  ventilation. 

A  harassing  cough  sacrifices  rest  and  sleep.  It  must  be  met  by  small 
doses  of  codeine  phosphate,  gr.  1/24  (0.003  Gm.)  to  gr.  1/12  (0.005  Gm.) 
in  children  according  to  age,  in  older  children  and  in  adults  gr.  1/8 
(0.008  Gm.)  to  gr.  1/4  (0.015  Gm.)  every  two  hours.  Holt  advises 
Dover's  powders  in  doses  of  gr.  1/10  (0.006  Gm.)  every  two  hours  to  a 
child  of  one  year. 

I  have  no  great  faith  in  expectorants  and  fear  the  disturbance  to 
the  stomach  they  may  set  up. 

When  the  secretions  are  abundant  or  the  child  is  weak,  efforts 
at  expulsion  may  be  ineffectual.  Hot  and  cold  water  alternately  applied, 
or  hot  mustard  baths  may  excite  to  increased  respiration  and  save  from 
a  threatened  suffocation.  Oxygen  may  be  used  diluted  with  air  and 
the  chest  cupped. 

Delirium  and  sleeplessness  are  ameliorated  by  the  effects  of  cold 


498  TREATMENT  OF  ACUTE  INFECTIOUS  DISEASES 

air.  A  warm  bath  sometimes  invites  to  sleep.  An  ice  bag  to  the  head 
is  often  helpful.  For  headache  and  extreme  restlessness,  antipyrin  gr.  i 
(0.06  Gm.)  or  phenacetin  gr.  i  (0.06  Gm.)  or  gr.  ii  (0.15  Gm.)  or  Dover's 
powders  gr.  1/10  (0.006  Gm.)  to  infants  and  larger  doses  to  older  chil- 
dren every  three  or  four  hours. 

Care  of  the  diet  and  bowels  and  sufficiency  of  water  are  of 
prime  importance  when  respiration  is  embarrassed,  as  the  formation 
of  gas  produces  tympanites;  the  gas  presses  up  on  the  diaphragm  and 
encroaches  on  the  breathing  space  and  disturbs  the  heart  action.  To 
relieve  this  mild  salines  as  suggested,  enemata,  or  enteroclyses  of  warm 
salt  solution,  fomentations  (see  Typhoid  Fever,  Chap.  V),  the  introduc- 
tion of  a  rectal  tube  or  a  Murphy  drip  may  be  of  value. 

Cardio-vascular  failure  has  been  dealt  with  under  that  heading 
above. 

For  edema  of  the  lungs  consult  Pneumonia,  Chap.  IX  and  summary. 

Bronchitis.  Much  more  common  and  far  less  alarming  as  a 
complication  is  bronchitis  in  measles.  In  fact,  a  certain  degree  of  bron- 
chitis may  be  anticipated  in  a  well-developed  case.  The  treatment  has 
been  outlined  under  pneumonia,  for  all  gradations  of  bronchitis  are  to  be 
met  with  merging  insensibly  into  pneumonia  and  all  severe  cases  of 
bronchitis,  involving  the  bronchi  of  small  size  are  to  be  considered  as 
and,  indeed,  are  pneumonia. 

For  the  milder  grades,  one  may  try  as  described  above,  mustard 
pastes,  the  chest  compress,  inhalations  of  steam  or  steam  medicated 
with  benzoin,  creosote  or  eucalyptol,  the  latter  especially  when  the 
secretions  are  thick  and  viscid. 

For  the  cough,  if  severe  and  exhausting,  Dover's  powder  or  codeine 
in  doses  described. 

Laryngitis.  A  laryngitis  may  occur  early  or  late.  When  oc- 
curring early  it  probably  is  not  diphtheritic,  but  a  culture  of  the  throat 
should  be  taken.  If  occurring  late  it  probably  is  diphtheritic  and  should 
be  treated  as  such,  not  awaiting  upon  the  return  of  the  culture  which  is 
to  be  made,  but  giving  antitoxin  at  once,  10,000  units. 

Occurring  early  it  is  to  be  treated  like  laryngitis  under  other 
conditions. 

Local  Applications.  Heat  or  cold  in  the  shape  of  compresses, 
though  to  apply  cold  the  ice  bag  or  coil  may  be  used,  but  are  not  so 
easy  of  application  as  the  compress. 

Cold  Compress.  Old  linen  cut  into  a  strip  folded  three  or  four 
times  lengthwise,  long  enough  to  go  about  the  neck  and  pin.  Wring 
out  of  cold  water  at  60°  F.  Apply  to  the  throat  and  outside  of  this  a 
dry  flannel.  Renew  hourly. 


MEASLES  499 

Hot  Compresses.  A  thick  piece  of  old  flannel.  Lay  it  in  a  crash 
towel,  pour  over  it  boiling  water,  wring  it  in  the  towel  by  twisting  the 
ends  in  opposite  directions,  flirt  in  the  air  to  expel  the  excess  of  hot 
steam,  apply,  and  outside  of  it  a  dry  flannel,  renew  every  ten  or  fifteen 
minutes  for  three  or  four  times  and  apply  dry  flannel.  Repeat  at  three 
or  four  hour  intervals. 

Inhalations.  Steam  from  a  croup  kettle  under  the  tent  as  above 
described.  Compound  tincture  of  benzoin,  turpentine  or  eucalyptus  oil 
may  be  added,  3i  (4  c.c.)  upon  the  water  of  the  kettle. 

Warm  drinks  and  warm  milk.  A  glass  of  hot  milk  in  the  morn- 
ing will  often  relax  the  parts  and  aid  to  expel  the  secretions.  If  the 
secretions  are  thick  and  the  patient  old  enough  to  permit  it,  sprays  of 
sodium  bicarbonate  gr.  xx  to  the  ounce  (1.30  Gm.  to  30  c.c.),  telling 
the  patient  to  inhale  as  the  spray  is  injected,  will  "cut"  the  secretions 
and  help  to  discharge  them.  Sprays  in  an  oily  medium,  as  liquid  petro- 
latum, of  menthol,  eucalyptus  or  camphor  1  per  cent,  or  a  combination 
of  each  1  per  cent,  may  be  found  grateful. 

If  the  cough  is  harassing,  small  doses  of  codeine  as  for  bronchitis 
may  be  administered. 

Otitis.  Measles  is  second  to  scarlet  fever  only  in  the  frequency 
of  ear  involvement.  It  is  said  to  be  affected  in  10  per  cent,  of  the  cases, 
but  the  degree  of  impairment  and  the  seriousness  of  the  sequelae  is  much 
less.  Nevertheless  the  ear  should  be  regularly  inspected.  The  treatment 
is  in  the  application  of  dry  heat,  5  per  cent,  carbolic  (phenol)  in  glycerin 
to  relieve  the  pain  and  incision  when  bulging  is  obvious.  For  details  of 
the  treatment,  see  Scarlet  Fever,  Chap.  XVII. 

Adenitis.  Marked  involvement  of  the  cervical  glands  occur  in 
some  2  per  cent,  of  the  cases.  For  treatment,  see  Scarlet  Fever, 
Chap.  XVII. 

Ulcerative  Stomatitis.  Noma.  Both  these  conditions  may  com- 
plicate measles.  The  latter,  though  fortunately  rare,  is  more  commonly 
a  complication  of  measles  than  of  any  other  disease.  Not  only  is  it  highly 
fatal,  70  per  cent,  to  100  per  cent,  in  different  series,  but  if  it  spares,  it 
leaves  a  lamentable  deformity  and  scarring  of  the  part  affected,  most 
often  the  face.  Its  relation  to  ulcerative  stomatitis  is  believed  to  be  close, 
and  it  is  believed  that  the  noma  represents  a  more  virulent  process  in  a 
less  resistant  individual  than  does  the  ulcerative  stomatitis.  Both  are 
probably  due  to  the  fusiform  bacillus  of  Vincent. 

It  is  for  this  reason  that  such  great  care  should  be  exercised  on  the 
oral  toilet  in  measles. 

When  ulcerative  stomatitis  occurs,  in  addition  to  measures  advised 
in  the  care  of  the  mouth,  one  should  administer  chlorate  of  potash, 


500  TREATMENT  OF  ACUTE  INFECTIOUS  DISEASES 

gr.  ii  (0.130  Gm.)  every  one  or  two  hours  and  use  a  chlorate  of  potash 
solution  as  a  mouth  wash;  the  strength  should  be  1/4  per  cent,  to  1/2 
per  cent,  or  if  this  is  painful  more  dilute.  If  the  process  is  not  bettered 
by  these  efforts  one  may  touch  the  spots  with  10  to  50  per  cent,  nitrate 
of  silver,  or  chromic  acid  5  per  cent,  ur  tincture  of  iodine. 

If  the  process  is  succeeded  by  noma  or  begins  as  a  noma  one  uses  as 
an  irrigation  potassium  permanganate,  making  a  claret  colored  solution 
(1:5000),  and  has  recourse  to  more  heroic  measures  in  addition  to  those 
named. 

The  edges  of  the  gangrenous  process  is  touched  with  fuming  nitric 
acid  or  with  pure  carbolic  acid  (phenol)  followed  by  pure  alcohol.  The 
gangrenous  tissue  should  be  previously  clipped  away  or  the  edges 
curetted. 

The  best  opinion,  however,  favors  free  excision,  going  out  into  the 
healthy  tissue,  and  applying  the  Paquelin  cautery  to  the  edges.  This 
should  be  done  before  the  toxemia  has  robbed  the  patient  of  what  little 
resistance  may  be  left. 

MacGuire  recommends  the  application  of  a  thick  paste  of  subni- 
trate  of  bismuth  and  water  at  frequent  intervals.  I  have  seen  most 
intense  ulcerative  stomatitis  clear  up  under  this  treatment. 

In  a  hospital  the  child  affected  should  be  removed  from  the  ward 
and  isolated,  as  the  disease  seems  contagious. 

Noma  may  attack  the  vulva  and  is  to  be  similarly  treated. 

Gastro-Intestinal.  As  the  rash  fades  or  in  convalescence  an  ileo- 
colitis  may  occur  and  is  often  of  serious  import.  It  should  be  treated 
as  under  other  circumstances.  During  the  early  hours  no  food  should 
be  given,  but  water  freely,  in  small  quantities  frequently;  then  the  diet 
should  be  barley  water,  arrow-root  water,  rice-water,  broths,  chicken, 
mutton,  veal  or  beef  broth.  The  broths  may  be  thickened  with  farina- 
ceous foods,  barley,  arrow-root,  wheat  flour.  When  the  acuteness  of  the 
symptoms  have  passed  and  decided  improvement  in  the  stools  have 
occurred  milk  in  the  shape  of  boiled  skim  milk  may  be  begun,  cautiously 
at  first. 

The  bowels  should  be  moved  with  castor  oil,  5i  (4  c.c.)  to  a  child 
of  a  year  and  more  in  accordance  with  age.  The  colon  should  be  irrigated 
daily  with  saline  solution,  3i  to  a  pint  (4  Gm.-500  c.c.),  using  2  to  3 
quarts  (2-3  liters),  at  100°  F.  This  will  often  suffice,  but  if  the  stools 
persist,  bismuth  subnitrate  in  doses  of  gr.  xx  to  gr.  xxx  (1.30-2  Gm.) 
every  two  hours,  should  be  given,  the  dose  decreased  with  improvement 
in  the  stools.  It  can  be  given,  shaken  in  a  little  water,  through  which  it 
quickly  diffuses  in  suspension. 

The  drug  is  insoluble,  hence,  the  large  doses  can  be  given  to  the  child 


MEASLES  501 

as  well  as  the  adult.  The  object  is  to  give  enough  for  it  to  exert  its 
protective  effect  on  the  considerable  extent  of  the  gut  involved.  The 
castor  oil  should  be  repeated  every  two  or  three  days.  If  oil  cannot  be 
retained  Rochelle  salt,  5i  to  5iv  (4-15  Gm.)  can  be  substituted. 

Only  when  the  gut  is  certainly  clean  and  when  the  diarrhea  resists 
other  measures  should  opium  be  used,  in  children  in  the  shape  of  pare- 
goric, m.  v  (0.30  c.c.)  equal  to  gr.  1/48  opium  (0.0015  Gm.)  or  its  equiva- 
lent in  powder,  tincture  or  Dover's  powder,  every  two  or  three  hours. 
Lengthen  the  interval  promptly  with  improvement.  The  temptation 
to  use  opium  early  and  to  continue  it  instead  of  seeking  more  legitimate 
measures  of  relief  must  be  strenuously  combated.  In  severe  pain  or 
copious  exhausting  diarrhea,  morphine  sulphate  hypodermically,  gr.  1/48 
to  gr.  1/24  (0.0015-0.0003  Gm.)  at  a  year  to  two  years  may  be  used.  For 
lesser  pains  of  a  colicky  nature  fomentations  should  be  applied  to  the 
intestine. 

Diet  rather  than  drugs  should  afford  relief. 

Eyes.  More  or  less  conjunctivitis  is  common  enough  and  is  to 
be  treated  with  frequent  applications  of  boric  acid  solution,  2  per  cent, 
to  4  per  cent.  If  severe,  cold  cloths,  squares  of  linen  or  cheesecloth  may 
be  applied  frequently  and  over  a  considerable  period  of  time.  These 
cloths  are  put  on  bits  of  ice  in  saturated  boric  acid  solution  and  con- 
stantly renewed,  as  they  grow  warm  upon  the  eyes.  The  lids  are  kept 
separated  with  vaseline  smeared  along  the  edges.  In  purulent  conjunc- 
tivitis silver  salts  may  be  used,  such  as  argyrol. 

In  only  the  weakly  and  ill  nourished  patients  may  one  anticipate 
the  serious  complications,  an  involvement  of  the  cornea  with  ulceration. 
These  cases  need  expert  advice. 

In  blepharitis  apply  yellow  oxide  of  mercury  ointment,  gr.  i  (0.060 
Gm.)  of  oxide  to  3ii  to  iv  of  vaseline  (8-15  Gm.) 

If  there  is  much  photophobia  a  drop  of  atropine  sulphate  in  1/2  per 
cent,  solution  can  be  applied  to  the  eye  to  dilate  the  pupil.  Use  cau- 
tiously. 

The  eyes  must  be  shaded  or  the  room  somewhat  darkened. 

Heart  complications,  such  as  endocarditis  or  pericarditis  are  very 
rare  and  are  to  be  treated  as  under  other  circumstances. 

Kidney  involvement,  other  than  a  transient  albuminuria,  is  an 
uncommon  occurrence.  If  nephritis  does  occur  it  is  to  be  met  as  in 
scarlet  fever.  (See  Scarlet  Fever,  Chap.  XVII.) 

Diphtheria.  As  has  been  said,  any  membrane  on  the  tonsils, 
or  pharynx  should  demand  immediate  culture  to  determine  whether 
it  is  diphtheritic  or  not,  to  be  treated  accordingly.  If  laryngitis  inter- 
venes in  the  course  of  measles,  antitoxin  should  be  given,  10,000  units, 


502  TREATMENT  OF  ACUTE  INFECTIOUS  DISEASES 

without  awaitihg  the  report  on  the  culture.  In  the  hospital  all  cases 
should  receive  an  immunizing  dose  of  antitoxin. 

When  many  cases  of  measles  are  thrown  together  as  was  the  case 
in  our  camps  during  the  late  war  and  when  these  men  have  been  in 
intimate  contact  with  many  cases  of  infection  of  the  upper  air  passages, 
before  isolation  can  be  effected,  and  with  many  more  who  are  carriers 
of  the  streptococcus  hemolyticus,  secondary  infection  with  this  organism 
is  inevitable  and  it  was  this  secondary  infection  that  made  Measles  the 
horrible  plague  it  proved  to  be.  Complications  became,  under  these 
circumstances,  more  numerous,  more  varied  and  severe.  They  ranged 
through  an  extensive  gamut,  from  tonsillitis  adenitis,  sinusitis,  bron- 
chitis, otitis,  erysipelas,  to  bronchopneumonia  of  the  streptococcic  type, 
empyema,  peritonitis,  meningitis,  and  septicemia  and  have  to  be 
treated  as  streptococcic  infections.  See  Streptococcus  Pneumonia,  and 
Empyema,  Septicemia,  Erysipelas,  Cerebrospinal  Meningitis  (Chaps.  X, 
XLV,  XLVI,  and  XXV). 

Tuberculosis.  Measles  renders  the  patient  peculiarly  suscept- 
ible to  tuberculosis,  making  readily  possible  an  infection  or  lighting 
up  of  an  old  process  or  causing  the  breaking  down  of  and  extension 
from  tuberculous  bronchial  glands.  Cough  and  fever  persisting  should 
lead  to  repeated  careful  examinations  of  lungs  and  sputum.  Other 
tuberculous  complications,  such  as  meningitis  and  acute  military  tuber- 
culosis may  follow.  Such  possibilities  again  heighten  the  importance  of 
sedulously  avoiding  infection. 

Convalescence.  The  most  important  matter  in  consideration  of 
the  period  of  convalescence  is  the  susceptibility  to  tuberculosis.  Avoid- 
ance of  exposure  to  a  tubercular  environment  or  prompt  removal  from 
one,  hi  case  any  member  of  the  family  has  or  is  suspected  of  having 
tuberculosis;  avoidance  of  colds,  plenty  of  fresh  air  and  sunlight,  an 
abundance  of  good  food  and  tonics,  the  last  in  fact  the  least,  constitute 
our  efforts.  One  may  administer  iron,  Blaud's  pill  or  Vallet's  mass  in 
doses  of  gr.  ii  to  gr.  v  (0.130-0.30  Gm.)  three  times  a  day  according  to 
age,  or  the  bitter  wine  of  iron,  which  contains  5  per  cent,  of  the  citrate  of 
iron  and  quinine,  in  doses  of  3i  to  ii  (4r-S  c.c.)  three  times  a  day.  Strych- 
nine or  Tr.  nucis  vomicae,  in  doses  according  to  age  and  cod-liver  oil. 
This  latter  is  best  administered  to  children  without  effort  to  conceal  the 
taste,  in  doses  of  3ss.  to  i  (2-4  c.c.)  in  older  infants,  and  3i  to  ii  (4-8  c.c.) 
in  children. 

The  child  should  be  kept  hi  bed  until  the  rash  has  quite  disappeared 
and  then  in  the  absence  of  fever  or  complications  may  be  allowed  up 
and  in  another  week  or  ten  days  be  allowed  out. 

Release  from  Quarantine.     The  patient  should  be  given  a  warm 


MEASLES  503 

bath  with  soap  and  water  and  a  bath  of  bichloride  1  to  5,000.  The  hair 
should  be  shampooed. 

Disinfection.  For  discussion  of  terminal  disinfection,  see  Scarlet 
Fever,  Chap.  XVII.  The  virus  of  measles  does  not  cling  to  rooms  or 
articles  long.  If  the  room  occupied  is  thoroughly  cleansed  and  aired 
for  some  days  and  children  are  not  allowed  to  occupy  it  for  two  or  three 
weeks,  the  rigorous  disinfection  given  to  a  room  after  scarlet  fever  is  not 
necessary,  but  in  an  institution  or  when  children  must  occupy  the  room, 
such  rules  as  laid  down  for  disinfection  in  scarlet  fever  should  be  carried 
out.  Such  precautions  will  always  appeal  to  the  careful  parent. 

Clothes  and  utensils  may  be  disinfected  as  in  scarlet  fever.  (See 
Chap.  XVII.) 

SUMMARY 

Distribution  of  the  family. 
Exposed  children  are  almost  sure  to  catch  the  disease;  still  they  ought 

to  be  isolated  until  the  incubation  period  is  passed,  i.  e.,  two  weeks, 

then  kept  away  until  the  patient  is  well. 
Young  infants  have  a  greater  chance  to  escape,  and  their  isolation 

is  the  more  imperative. 
Exposed  children  should  be  kept  from  school  until  the  patient  has 

convalesced  and  the  incubation  period  is  passed. 

Room. 

In  hospitals,  separate  cubicles. 

Choice  and  management. 

(See  summary  under  Scarlet  Fever,  Chap.  XVII.) 

Eyes. 

May  be  protected  by  the  position  of  the  bed. 

By  the  use  of  screens. 

By  the  use  of  colored  glasses. 

By  slightly  darkening  the  room. 

Patient's  comfort  the  best  regulator  of  light. 

Fresh  air. 

Temperature  of  room  65°  F.-700  F. 

In  toxic  condition,  cold  air,  with  body  properly  protected.  Two 
rooms  adjoining — one  to  be  exposed  to  fresh  air  and  sunlight, 
when  not  occupied,  is  excellent. 

Never  treat  two  patients  in  the  same  room  on  account  of  the  con- 
tagiousness of  the  complications. 

Nurse. 

Nurse  for  each  patient,  or  if  impossible  wear  a  mask  for  each  patient. 
Must  have  no  contact  with  other  children  or  susceptible  adults 

either  when  she  is  on  duty  or  during  her  hours  off  duty. 
Wear  gown. 


504  TREATMENT  OF  ACUTE  INFECTIOUS  DISEASES 

Physician. 

Should  not  go  directly  to  another  child. 
Wear  gown  and  gloves  in  sick  room. 
Wash  hands  on  leaving  with  soap  and  water. 
Follow  with  alcohol  or  1-1000  bichloride. 
Wear  mask  to  avoid  becoming  a  carrier. 

Precautions  in  sick-room. 

(See  summary  under  Scarlet  Fever,  Chap.  XVII.) 
If  there  are  no  other  children  in  the  family,  soaking  clothes  in  dis- 
infectant before  going  to  the  family  wash  is  not  necessary. 

Bed. 

Choice  and  preparation. 

(See  summary  under  Scarlet  Fever,  Chap.  XVII.). 

Patient. 

Nightgown,  cotton  or  linen,  or  if  cold  air  is  admitted,  flannel. 
Open  all  the  way  down  the  front  or  sides  to  facilitate  examinations. 

Bath. 

Soap  and  tepid  or  cool  water. 

Between  blankets,  if  desired. 

Room  temperature  70°  F.  or  over  during  the  bath. 

Diet. 

Do  not  urge  food  during  early  days. 

During  short  course  of  a  normal  measles  leave  quantity  to  the  patient's 

inclination. 
When  prolonged  by  complications  the  protein  and   caloric  needs 

must  be  considered. 
t  (See  Chap.  II  and  Chap.  XIV.) 
'  Young  infants. 

Dilute  the  milk  mixture  one-quarter  to  one-half  with  water  or  thin 

cereal  water. 
Older  infants. 

Milk  had  better  be  somewhat  diluted. 
Older  children  and  adults. 

Milk  gruels  of  arrowroot,  barley,  wheat-flour,  cornstarch,  farina 
or  imperial  granum  or  small  quantities  of  cereals  with  milk, 
cream  and  sugar,  jellies  of  barley,  tapioca  and  sago,  boiled  rice, 
milk  toast,  milk  modifications,  eggs,  ice  cream.  As  the  fever 
declines,  bread  and  butter,  custard,  raw  oysters,  chicken  and 
mutton  broths,  thickened  with  rice,  arrowroot,  etc.  With  normal 
temperature  scraped  beef,  squab,  chicken,  lamb  chop  minced. 
Water  freely. 

Alkaline  waters,  lemonade,  orangeade,  imperial  drink. 

Fruit  juices  ma}r  be  sweetened. 

(For  caloric  values  see  Typhoid  Fever,  Chap.  XIV.) 


MEASLES  505 

Skin. 

Cleansing  bath  each  day. 
Itching  and  burning. 

Bicarbonate  of  soda  3i  to  Oiii  water  (4  Gin.  to  1,500  c.c.). 

Bran  water  dabbed  on  skin. 

A  handful  of  common  bran  in  a  cheesecloth  or  muslin  bag  swished 

about  in  a  gallon  of  water  until  milky. 
When  more  severe. 

One  per  cent,  to  2  per  cent,  of  phenol  in  vaseline  or  olive  oil. 
When  desquamation  begins. 

Anoint  with  vaseline  after  daily  bath. 

Mouth. 
(For  details  see  summary  under  Scarlet  Fever,  Chap.  XVII.) 

Nose. 

Moisten  dried  secretions  with  sweet  oil. 

Use  swabs  on  wooden  toothpicks  as  applicators  or  sprays  of  same 

solutions  as  in  mouth. 

Physiological  salt  solution  3i  to  Oi  (4  Gm.-500  c.c.). 
Two  per  cent,  boric  acid  solution. 
Quarter  to  half  strength  DobelTs  solution. 

Eyes. 

Cleansed  twice  a  day  or  oftener. 

Use  saturated  (4  per  cent.)  boric  acid  solution. 

Anoint  the  lids  with  vaseline  to  prevent  sticking. 

Genitals. 
Keep  clean  with  2  per  cent,  to  4  per  cent,  boric  acid  solutions. 

Bowels. 

When  first  seen. 
Infant  or  very  young  child. 
Castor  oil  3i  to  3ii  (4-8  c.c.). 
or 
Calomel,  gr.  1/10  to  gr.  1/4  (0.006-0.015  Gm.)  every  ten  to  fifteen 

minutes  until  gr.  i  (0.060  Gm.)  is  taken. 
Older  children  and  adults. 

Salts.     Epsom,  Rochelle,  Glauber's  or  Sodium  phosphate  3ii  to 
3iv  (8-15  Gm.)  in  half  glass  of  water.    Give  alone  or  preceded 
by  calomel,  gr.  i  to  gr.  iss.  (0.060-0.10  Gm.)  in  divided  doses. 
Children. 
Liquor  magnesii  citratis  3vi  to  gvu'j   (180-240  c.c.)   or  milk  of 

magnesia  5ss.  (15  c.c.). 
Later. 

Move  bowels  at  least  every  other  day  by  enema,  liquor  magnesii 
citratis  or  Hunyadi  water. 


506  TREATMENT  OF  ACUTE  INFECTIOUS  DISEASES 

Fever.  :^»  , 

When  moderate,  below  104°  F.  let  alone. 
Hyperexia. 

Sustained  above  104  F.,  or  sudden  above  105°  F.,  use  cold  water. 

Infants,  sponge. 

Children,  pack  or  sponge. 

Older  children  and  adults;  bath  or  pack. 

Baths  for  children,  if  given,  should  be  graduated. 

The  younger  the  child  the  wanner  the  bath. 

Begin  at  98°  F.  to  95°F.  and  cool  down  to  85  °F. 

Be  satisfied  when  patient 's  temperature  falls  to  102°  F. 

Keep  ice-bag,  cold  cloths,  to  head  or  sponge  head  with  cold  water. 
Collapse  during  bath. 

Wrap  in  warm  blankets. 

Heat  to  extremities. 

Hot  drinks. 
High  temperature,  cold  extremities,  bad  color  and  small  pulse. 

Mustard  bath. 

5ss.  (15  Gm.)  mustard  to  1  gallon  (4  liters)  water. 

Add  mustard  to  a  small  amount  of  luke  warm  water  to  develop  the 

oil,  then  add  hot  water  to  100°  F. 
Put  child  in. 

Bring  temperature  up  to  105°  F. 

Leave  in  five  to  ten  minutes. 

Dab  dry  and  roll  in  warm  blanket. 

Put  heat  to  feet  and  ice  bag  to  head. 

Circulatory  failure. 
(See  Scarlet  Fever,  Chap.  XVII,  and  see  text.) 


Nervous  symptoms. 

Delirium. 

Warm  baths  or  sponges. 

Sponges,  packs,  baths.    (See  above  under  Fever.) 
Ice  bag  to  head. 
Drugs. 

Only  when  other  measures  are  not  efficacious  or  attainable. 
Young  children. 

Antipyrin,  gr.  i  (0.060  Gm.)  three  times  a  day. 

Phenacetin,  gr.  i  to  ii  (0.06(M).130  Gm.). 

Sodium  bromide,  gr.  iii  to  iv  (0.20-0.25  Gm.)  three  times  a  day. 
Older  children. 

Sodium  bromide,  gr.  v  (0.30  Gm.)  three  or  four  times  a  day. 

Adults. 

Sodium,  potassium  or  ammonium  bromide  or  any  combination  of 
these,  gr.  xv  to  gr.  xxx  (1-2  Gm.)  three  or  four  times  a  day. 


Sleeplessness. 
Children. 
Warm  baths. 


MEASLES  507 


above  under  Delirium' 
Phenacetin. 
Adults. 
Trional,  gr.  x  to  xv  (0.60-1  Gm.)  as  a  powder  or  in  warm  water, 

whisky,  brandy  or  wine. 
Repeat  in  two  hours  if  needed. 

Chloralamid,  gr.  xx  to  gr.  xxx  (1.30-2  Gm.)  in  powder  or  cold 
water  (heat  decomposes)  or  wine,  whisky  or  brandy,  and  repeat 
in  two  hours  if  needed. 

Wild  delirium. 

Morphine  sulphate  hypodermically,  gr.  1/48-1/4  (0.0015-0.015  Gm.) 
according  to  age. 

Complications. 

Bronchopneumonia. 
Remove  from  the  ward  or  other  cases  to  prevent  its  spread  to 

others. 

Treat  as  a  pneumonia. 
(See  Pneumonia,  Chap.  IX.) 
(See  text.) 
It  includes 

Cold  air. 

Watch  cases  of  capillary  bronchitis. 
They  often  do  better  in  a  warmer  air. 
Early  stages. 

Mustard  paste  to  whole  chest  every  three  or  four  hours. 

(For  technique  see  Pneumonia,  Chap.  IX.), 
Fever. 

Sponges,  packs  and  baths  of  cold  water. 
Cough. 

Open  air. 

Chest  compresses. 
Steam  inhalations  under  tent. 

Benzoin. 

Creosote. 

Water  left  in  shallow  dishes  in  room  for  moisture. 

Don't  get  air  too  moist. 

Remove  child  once  in  a  while  to  air  the  room. 

Codeine  phosphate,  gr.  1/24-1/4  (0.0025-0.015  Gm.). 

Dover's  powder,  gr.  1/10  (0.006  Gm.). 
Every  two  hours  at  one  year  (Holt). 

Expectorants  not  advised. 

Feeble  expulsion  of  secretions. 

Applications  alternately  of  hot  and  cold  water. 

Hot  mustard  baths.    (See  above.) 


508  TREATMENT  OF  ACUTE  INFECTIOUS  DISEASES 

Oxygen  inhalations  diluted  with  air. 
Cupping  xjhest. 

Changing  position  from  time  to  time. 
Give  water  freely. 
Treatment  of  cardiac  failure  and  edema  of  lungs.    (See  Pneumonia, 

Chap.  IX.) 
Tympanites. 
Mild  salines. 


Enteroclysis. 


(See  Typhoid  Fever  summary,  Chap.  XIV.) 


Murphy  drip. 

Rectal  tube. 

Fomentations.  * 

(For  technique  of  above  measure  see  Pneumonia,  Chap.  IX.) 

Bronchitis. 

Treat  like  a  mild  pneumonia. 
Laryngitis. 

Early;  probably  not  diphtheritic. 

Culture  should  be  taken,  however. 
Late;  probably  diphtheritic. 

Give  antitoxin  at  once,  10,000  units,  preferably  into  vein. 
Early. 
Heat. 

Compresses,  Technique.    (See  text.) 
Cold. 

Compresses,  Technique.    (See  text.) 
Ice  coil. 
Ice  bag. 
Inhalations. 
Steam. 

Steam  medicated  with  compound  tincture  of  benzoin,  oil  of  eu- 
calyptus or  turpentine,  5i  (4  c.c.)  to  the  pint  (500  c.c.)  water. 
(For  technique,  see  Scarlet  Fever,  Chap.  XVII.) 
Warm  drinks,  especially  in  the  morning. 
Sprays. 

Bicarbonate  of  soda,  gr.  xx  to  gi  (1.30  Gm.-30  c.c.). 
Sprays  of  oils. 
Menthol. 
Eucalyptus. 
Camphor. 

Individually  or  in  combination  in  1  per  cent,  strength. 
For  cough. 

Codeine  phosphate  or  sulphate,  gr.  1/24  to  1/4  (0.0025-0.015 
Gm.)  according  to  age. 

Otitis. 

Daily  examination  of  the  ears. 
For  earache. 

Dry  heat. 

Five  per  cent,  phenol  in  glycerin.    Drop  in  ear. 


MEASLES  509 

Bulging. 

Incise. 
(For  details  and  technique,  see  Otitis  in  summary  of  Scarlet  Fever, 

Chap.  XVII.) 

Adenitis. 

(See  Adenitis  in  summary  of  Scarlet  Fever,  Chap.  XVII.) 

Ulcerative  Stomatitis. 

Usual  solutions  for  cleanliness. 

Chlorate  of  potash,  gr.  ii  (0.13  Gm.)  in  water  internally  every  two 

hours.    (Doubtful  importance.) 
Chlorate  of  potash  */£  per  cent,  to  J£  per  cent,  solution  locally  mouth 

wash. 

Silver  nitrate  10  per  cent,  to  50  per  cent  solution — touch  ulcers. 
Tr.  Iodine,  or  5  per  cent,  chromic  acid  solution. 

Paint  on  ulcers. 
MacGuire's  method;  see  below  under  Noma. 

Noma. 

Irrigate  with  potassium  permanganate  (make  deep  claret  red  solu- 
tion). 

Clip  away  gangrenous  tissue  or  curette  the  edge. 

Touch  the  edge  after  curetting  with  fuming  nitric  acid,  or  liquified 
phenol,  followed  by  absolute  alcohol. 

Better  yet  free  excision,  cut  into  healthy  tissue  and  touch  edge  with 
Paquelin  cautery. 

MacGuire's  method;  cover  affected  area  every  two  or  three  hours 
with  a  thick  paste  of  water  and  subnitrate  of  bismuth.  Remove 
child  from  other  cases. 

Noma  of  vulva. 
Treat  in  same  way  as  noma  in  mouth. 

Gastro-Intestinal 

Ileo-Colitis. 

Stop  food  during  early  hours. 
Give  water  in  small  quantities  very  frequently. 
Then 

Barley-water,  arrowroot  or  rice  water,  mutton,  veal  or  beef  broth, 
then  thicken  with  farinaceous  foods,  barley,  arrowroot,  rice, 
wheat  flour,  then  as  stools  improve  add  boiled  skim  milk  and 
gradually  get  back  on  diet. 
Castor  oil,  3i  to  ii  (4-8  c.c.)  at  one  to  two  years. 
Colon  irrigation  to  be  given  daily. 

Use  salt  solution  3i  to  Oi  (4-500  c.c.)  2  to  3  quarts  at  100°  F. 
If  loose  stools  still  persist  give  bismuth  subnitrate,  gr.  xx  to  gr.  xxx 
(1.30-2  Gm.)  every  two  hours,  the  interval  being  lengthened  as 
stools  decrease.    Give  it  shaken  in  a  little  water. 
Castor  oil  should  be  repeated  every  second  or  third  day. 


510  TREATMENT  OF  ACUTE  INFECTIOUS  DISEASES 

If  oil  is  not  retained  give, 

Rochelle  salt  5i  to  iv  (4-15  Gm.). 

If  above  measures  fail,  and  only  when  the  gut  has  been  thoroughly 
•  emptied  by  the  cathartic,  give 

Opium,  gr.  1/48  (0.0015  Gm.)  or  its  equivalent  m.  v  (tiiSO  c.c.) 
paregoric  or  equivalent  amounts  in  tincture  or  Dover's  powder. 
Lengthen  intervals  with  improvement. 
Copious  and  exhausting  movements. 
Morphine  sulphate  hypodermically,  gr.  1/48  to  gr.  1/24  (0.0015- 

0.0025  Gm.)  at  one  to  two  years. 
Colicky  pains. 

Fomentations;  technique,   see   Typhoid   Fever  summary,   Chap. 

XIV,  or  Dysentery,  Chap.  XVI. 
Very  severe  pain. 

Morphine  sulphate  hypodermically,  gr.  1/48  (0.0015  Gm.)  at  one 
year  to  gr.  1/24  (0.0025  Gm.)  at  two  years. 

Eyes. 

Conjunctivitis. 

Careful  cleansing  with  saturated  boric  acid  solutions. 
If  severe. 
Cold  cloths,  i.  e.,  squares  of  linen  or  cheesecloth,  wet  in  boric 

acid  solution  and  kept  cold  on  ice  until  used. 
Apply  vaseline  to  margins  of  lids  to  prevent  sticking. 
Purulent  conjunctivitis. 

Irrigation  with  boric  acid  solution. 
Instillation  of  silver  salts,  e.  g.,  argyrol. 
Ulcers  of  cornea. 

Should  seek  expert  advice. 
Blepharitis. 

Yellow  oxide  of  mercury,  gr.  i  to  5ii  or  3iv  vaseline  (0.30  to  8  or 
15  Gm.). 
Smear  on  lids. 
Photophobia. 

Shade  eyes  or  darken  room. 

Atropine  sulphate  to  dilate  the  pupil,  J^  per  cent,  solution.    Use 
cautiously. 

Heart  complications  rare. 
Treat  as  under  other  circumstances. 

Kidney  complications  rare. 

Nephritis. 

Treat  as  in  Scarlet  Fever.    (See  summary,  Chap.  XVII.) 

Diphtheria. 
If  there  is  a  membrane  on  the  tonsils,  take  a  culture. 

Early  laryngitis. 
Take  a  culture. 


MEASLES  511 

Late  laryngitis. 
Give  antitoxin  10,000  units  into  vein.     Don't  wait  for  return  on 

culture. 

Hospitals  give  all  cases  an  immunizing  dose. 
(See  Diphtheria,  Chap.  XVIII,  for  treatment.) 

Tuberculosis. 

If  cough  and  fever  continue,  suspect  tuberculosis. 
Examine  lungs  repeatedly. 
Examine  sputum  repeatedly. 

Convalescence. 

Avoid  exposure  to  a  tuberculous  environment. 
Avoid  taking  cold. 
Fresh  air. 
Good  food. 
Drugs. 
Iron. 
Blaud's  pill,  better  Vallet's  mass  in  capsule  gr.  ii  to  v  (0.15- 

0.30  Gm.)  three  tunes  a  day. 
Vinum  ferri  amarum  (bitter  wine  of  iron)  3i  to  ii  (4-8  c.c.) 

three  times  a  day. 

Strychnine  sulphate  gr.  1/200  to  gr.  1/60  (0.0005-0.001  Gm.). 
Tincture  of  mix  vomica  m.  i-x  (0.06-0.60  c.c.),  according  to  age, 

three  times  a  day. 
Cod  liver  oil. 

3i-ii  (4-8  c.c.)  three  times  a  day. 
Allow  up. 

When  rash  and  fever  are  gone. 
Allow  out. 

A  week  or  ten  days  later. 

Release  from  quarantine. 

Give  bath  of  soap  and  water. 

Follow  with  bath  of  bichloride  1-5,000. 

Give  shampoo. 

Disinfection. 

Room  cleaned  and  aired  for  a  few  days. 

Put  no  children  in  this  room  for  two  or  three  weeks. 

The  cautious  parent  and  institutions  will  prefer  disinfection  as  in 

Scarlet  Fever.    (See  summary,  Chap.  XVII.) 
Clothes  and  utensils  may  be  disinfected  as  hi  Scarlet  Fever.     (See 

Chap.  XVII.) 


CHAPTER  XX 

RUBELLA 

(GERMAN  MEASLES) 

RUBELLA  may  be  considered  the  mildest  of  the  exanthems.  Such 
importance  as  it  has  rests  on  the  fact  that  mild  cases  of  scarlet  fever 
or  measles  may  be  mistaken  for  it  and  entail  great  risk  to  others. 

The  rash  is  likely  to  be  confluent,  which  simulates  scarlet  fever  and  is 
formed  especially  on  the  abdomen  and  the  inner  aspect  of  the  thigh. 

It  is  hardly  safe  to  make  a  diagnosis  of  German  measles  in  an  isolated 
case.  In  an  epidemic  the  diagnosis  is  relatively  easy. 

In  addition  to  the  rash  the  most  striking  feature  of  the  disease  is  the 
enlargement  of  the  superficial  glands,  especially  the  posterior  cervical, 
posterior  auricular  and  suboccipital  glands. 

In  isolated  cases  or  in  the  early  cases  of  an  epidemic  it  is  much  safer 
to  isolate  the  case  and  treat  it  as  a  scarlet  fever  suspect  until  the  appear- 
ance of  further  cases  settles  the  doubt. 

This  disease  occurs  much  more  frequently  in  adults  than  any  of  the 
exanthems,  though  it  is  rare  after  middle  life. 
The  incubation  period  is  from  two  to  three  weeks. 
Isolation.  Many  physicians  think  it  hardly  necessary,  so  mild 
is  the  disease  and  so  very  rare  the  complications,  but  if  the  physician, 
like  the  author,  believes  no  infection  is  so  trivial  as  to  be  neglected,  other 
children  will  be  sent  away,  if  that  can  be  done  without  exposing  other 
children,  and  will  be  kept  from  school  until  the  period  of  incubation 
expires,  that  is  three  weeks.  If  this  is  not  done  these  "contacts"  should 
be  watched,  and  with  any  evidence  of  catarrh,  trivial  at  the  most,  or 
with  frank  enlargement  of  the  glands  of  the  neck,  they  should  be  isolated. 
The  fever  is,  with  the  rarest  exception,  of  little  moment  and  complica- 
tions so  unusual  as  to  be  suspected  of  being  coincidences.  However,  in 
an  epidemic  in  and  about  Little  Rock,  Ark.,  observed  by  Geiger  there 
occurred  as  complications  acute  arthritis  in  a  considerable  per  cent,  of 
the  cases,  two  cases  of  acute  nephritis  and  one  of  endocarditis.  Such 
complications  are  to  be  treated  as  indicated  under  Acute  Rheumatic 
Fever,  for  Arthritis  and  Endocarditis  (Chap.  Ill),  Nephritis  under 
Scarlet  Fever  (Chap.  XVII). 

It  is  well  to  have  the  patient  keep  the  bed  during  the  few  days  of 


RUBELLA  513 

temperature;  allow  out  of  bed  a  couple  of  days  after  and  out  of  the 
house  in  a  couple  of  days  more. 

Sponge  baths  once  or  twice  a  day  for  cleanliness  and  comfort,  moving 
the  bowels  at  the  beginning  with  calomel  or  salts  or  both  and  avoiding 
constipation  after,  making  the  diet  fairly  liberal,  milk  and  milk  products, 
broths,  gruels,  bread  and  butter,  toast,  cereals,  eggs,  rice,  custards,  ice 
cream  during  the  febrile  period  and  meat  and  vegetables  after  the  febrile 
period,  giving  water,  or  lemonade  freely,  taking  care  of  the  mouth,  by 
the  use  of  boric  acid  or  Dobell's  solution  constitute  the  treatment. 

Fresh  air  and  sunlight  and  good  nursing  are  the  sum  total  of  treatment. 

There  is  scarcely  the  necessity  for  the  rigid  fumigation  and  disinfection 
one  carries  out  in  scarlet  fever  and  measles. 

If  the  room  is  thoroughly  cleaned  and  thoroughly  aired  for  a  few  days, 
it  meets  all  the  requirements.  If  disinfection  is  done,  the  rules  may 
be  found  under  Scarlet  Fever,  Chap.  XVII. 

SUMMARY 
Isolation. 

Contacts  should  be  kept  from  other  children  until  the  incubation 
period  of  three  weeks  are  passed. 

Because  the  disease  is  so  trivial  protest  is  made  against  keeping  con- 
tacts from  school  through  incubation  period. 

At  least,  the  slightest  sign  of  catarrh  or  enlargement  of  cervical  glands 
should  demand  isolation. 

In  sporadic  cases  isolation  is  imperative,  because  cases  so  diagnosed 
are  repeatedly  mistaken  diagnoses  of  mild  Scarlet  Fever. 

Bed. 
If  there  is  fever,  keep  patient  in  bed  until  gone. 

Baths. 
Sponge  of  soap  and  water  for  cleanliness. 

Bowels. 

Move  at  the  beginning  with  castor  oil  Si  to  iv  (4-15  c.c.).  Calomel 
in  divided  doses  gr.  1/4  (0.015  Gm.)  every  quarter  hour  for  four 


Follow  by  salts  3i  to  iv  (4-15  Gm.)  or  salts,  Epsom,  Rochelle  or 
Glauber's  alone  in  same  doses  or  liquor  magnesii  citratis  5vi  to 
viij  (180-240  c.c.)  or  milk  of  magnesia  5ss.  (15  c.c.). 

Diet. 

Fairly  liberal. 

During  fever  milk  or  milk  products,  broths,  gruels,  bread  and  butter, 

toast,  cereals,  eggs,  rice,  custard,  ice  cream. 
Water,  lemonade,  orangeade,  imperial  drink,  freely. 


514  TREATMENT  OF  ACUTE  INFECTIOUS  DISEASES 

Care  of  mouth*. 

Use  boric  acid  solution,  2  per  cent,  to  4  per  cent.,  or 
DobelTs  solution,  half  to  quarter  strength. 

Complications. 

EndolSditis.  }  (See  Acute  Rheumatic  Fever,  Chap.  III.) 
Nephritis.    (See  Scarlet  Fever,  Chap.  XVII.) 

Fresh  air. 

Allow  out  of  bed  two  days  after  fever  subsides. 
Allow  out  in  two  days  more. 
Cleanse  room  and  air  it  thoroughly. 


CHAPTER  XXI 

VARICELLA 

(CHICKEN  POX) 

VARICELLA  is  essentially  a  disease  of  childhood  and  is  so  because  it 
is  so  contagious  that  few  children  avoid  it;  but  adults  who  have  so  far 
succeeded  in  doing  so  are  equally  susceptible  when  exposed.  The  con- 
tagion is  usually  direct,  but  it  may  be  conveyed  by  a  third  person, 
particularly  if  the  conveyance  is  immediate. 

Distribution  of  the  Family.  It  is  so  trivial  in  its  effects  that 
much  disturbance  of  the  family  to  effect  isolation  seems  hardly  war- 
rantable and,  moreover,  other  children  are  pretty  sure  to  have  been 
infected  before  the  disease  is  recognized ;  for,  as  a  rule,  the  first  suspicion 
of  its  presence  is  aroused  by  the  eruption.  There  are,  however,  excep- 
tions to  the  statement  just  made  and  that  in  the  case  of  delicate  children. 
Mild  though  it  be  in  the  vast  majority  of  instances,  it  is  possible  for  it  to 
run  a  severe  course  and  unexpected  and  rare  complications  may  ensue. 
We  would  not  willfully,  therefore,  expose  children  and  the  children  of  the 
family  should  be  kept  from  other  children  to  prevent  the  spread  of  disease 
and  that,  of  course,  means  that  children  should  be  kept  from  school. 
Some  writers  say  it  is  warrantable  to  let  children  attend  school  for  the 
first  ten  days  after  exposure,  but  that  ought  to  mean  only  when  the  first 
exposure  is  certainly  known  and  when  there  is  no  contact  of  the  school 
child  with  the  patient. 

Contacts,  if  removed  from  the  patient,  should  be  kept  from  other 
children  until  the  period  of  incubation  has  passed,  which  should  be 
considered  in  such  cases  as  three  weeks. 

Room.  A  light  and  well  aired  room  should  be  chosen  for  this  patient 
and  isolation  may  not  be  so  strict  as  in  the  more  severe  exanthems, 
unless  any  individuals  are  coming  into  contact  with  other  children. 

The  physician  can  convey  the  disease,  though  with  a  thorough  airing 
and  avoidance  of  visiting  a  child  immediately,  it  is  not  likely  to  happen. 

Patient.  If  there  is  no  fever  nor  malaise,  as  is  frequently  the 
case,  confinement  to  the  bed  is  unnecessary,  but  if  either  of  the  above 
mentioned  conditions  obtain,  the  patient  should  remain  in  bed. 

When  the  eruption  is  abundant  a  regular  cleansing  bath  cannot  be 
given  without  the  risk  of  breaking  and  infecting  the  vesicles,  an  acci- 
dent which  it  is  desirable  to  prevent. 


516  TREATMENT  OF  ACUTE  INFECTIOUS  DISEASES 

The  diet  iirthe  light  case  need  in  a  property  fed  child  be  scarcely 
modified.  If  fever  of  a  light  grade  is  present,  all  but  solid  foods  may 
be  given;  if,  as  rarely  happens,  the  fever  is  high,  food  should  not  be 
forced,  for  the  fever  will  subside  in  a  day  or  two.  In  the  meantime, 
milk  and  milk  preparations  and  farinaceous  gruels  may  be  given. 

Water  should  be  allowed  freely. 

Skin.  The  one  object  of  real  consideration  is  the  skin;  for  the 
nature  of  the  eruption  leads  to  scarring,  which  on  the  face,  especially 
of  a  girl,  is  to  be  rigorously  avoided. 

The  eruption  itches,  the  young  child  scratches  and  even  older  children, 
who  endeavor  to  avoid  doing  so  are  sure  to  lacerate  some  of  the  vesicles, 
inadvertently  or  in  their  sleep  and  infect  the  lesions,  causing  an  increased 
damage  to  the  skin  and  in  some  instances  setting  up  erysipelas. 

The  eruption  should  be  kept  as  dry  as  possible  and  dusting  pow- 
ders of  sterile  talcum  powder  or  equal  parts  of  starch,  zinc  oxide  and 
boric  acid  may  be  used  for  this  purpose. 

In  young  children  the  scratching  can  be  avoided  by  putting  the 
arms  in  splints,  by  putting  on  stiff  cardboard  cuffs,  reaching  well  above 
and  below  the  elbows,  thus  preventing  the  bending  of  the  arms  and 
scratching  of  the  face.  Less  efficacious,  but  less  trying  for  the  little  one, 
are  wrapping  the  hands  in  gauze  and  cutting  close  the  nails. 

When  pustules  form,  especially  on  the  face,  they  should  be  evacuated 
by  incising  the  edge  of  the  pustule  with  a  small  spear-pointed  lancet 
or  a  Hagedorn  needle,  squeezing  out  the  pus  and  in  very  bad  ones  irri- 
gating with  a  fine  pointed  dropper  with  rubber  bulb  attached,  using 
boric  acid  or  diluted  peroxide  of  hydrogen,  half  to  quarter  strength. 
The  vesicle  should  not  be  denuded. 

Some  men  advocate  painting  the  vesicles  with  equal  parts  of  tincture 
of  iodine  and  alcohol  as  a  protective. 

To  control  the  itching  the  skin  may  be  dabbed  with  a  solution  of 
bicarbonate  of  soda  1  dram  to  the  pint  (4  Gm.  to  500  c.c.)  or  stronger, 
or  1  to  5  per  cent,  phenol  in  sweet  oil  or  vaseline  be  applied.  In  intense 
itching  even  10  per  cent,  is  used,  but  only  over  confined  areas. 

The  following  prescription  has  been  advised  by  Bethea : 


Phenolis gr.  v 

or 

Camphorse gr.  xv 

M.  et  adde. 

Hydrg.  Ammon gr.  xv 

Ung.  Sulphuris q.  s.  ad      gi 

Sig:  Apply  as  directed. 


VARICELLA  517 

In  severe  cases  there  may  be  some  stomatitis.  The  mouth  should 
be  cleansed  after  each  feeding  and  a  mouth  wash  of  salt  solution  .6  per 
cent.,  DobelFs  solution  half  strength,  or  2  to  4  per  cent,  boric  acid  solu- 
tion used  as  a  preventative. 

Bowels.  When  first  seen  the  child  should  be  given  a  mild  sa- 
line, milk  of  magnesia  3ii-iv  (8-15  c.c.),  or  liquor  magnesii  citratis 
5iv  to  viii  (180-240  c.c.). 

Constipation  should  be  avoided  by  a  repetition  of  the  dose  or  an 
enema. 

Fever.  The  fever  is  so  slight  as  to  require  no  treatment  as  a 
rule.  In  the  rarer  cases  cold  air  or  dabbing  the  skin  carefully  with 
cool  water  or  an  evaporation  bath  might  be  tried. 

Nervous  symptoms  are  largely  due,  when  they  occur,  to  the 
irritation  of  the  skin.  The  applications  to  the  skin  advised  allay  them 
in  a  measure,  but  bromides  in  doses  of  gr.  v  to  gr.  x  (0.30-0.60  Gm.) 
according  to  the  age,  two  years  to  ten  years,  are  indicated.  This  may  be 
repeated  every  four  to  six  hours. 

Complications.  Any  complication  is  unusual,  but  now  and  then 
the  following  occur;  stomatitis  (for  treatment  see  Measles,  Chap.  XIX), 
conjunctivitis  (for  treatment  see  Measles,  Chap.  XIX). 

Corneal  ulcer,  which  may  be  treated  with  1  per  cent,  atropine,  pow- 
dered dionin  and  5  per  cent,  yellow  oxide  of  mercury  (Wyler). 

Nephritis  (for  treatment  see  Scarlet  Fever,  Chap.  XVII). 

Herpes  Zoster,  which  is  to  be  treated  by  careful  protection,  keeping 
the  part  dry  by  applying  sterile  dusting  powders  or  painting  with  collo- 
dion, the  object  being  to  prevent  infection,  to  which  the  trophic  changes 
in  the  lesion  render  it  peculiarly  susceptible  and  erysipelas. 

Convalescence  is  rapidly  established  and  if  it  has  been  a  severe 
attack  iron  may  be  indicated  as  a  tonic,  but  in  my  estimation  fresh 
air  and  food  are  far  better  for  such  a  purpose. 

Release  from  Quarantine.  The  patient  may  be  considered  as 
no  longer  a  source  of  infection  when  the  last  scab  has  dropped  off.  By 
this  time  he  is  ready  to  go  out  and  is  allowed  to  do  so  after  a  thorough 
cleansing  bath  and  shampoo. 

Disinfection.  The  room  needs  only  good  cleaning  and  airing 
for  a  few  days. 

SUMMARY 

Distribution  of  the  family. 
Rare  for  any  member  of  the  family  to  escape  it. 
Usually  is  so  light  that  isolation  of  other  children  is  hardly  advisable. 
Exception  should  be  made  in  the  case  of  sickly  children,  who  should 
be  removed  from  the  environment  of  the  patient. 


518  TREATMENT  OF  ACUTE  INFECTIOUS  DISEASES 

School. 

Some  physicians  let  exposed  children  go  to  school  for  ten  days  but 

only  when  date  of  first  contact  is  surely  known. 
Contacts  should  be  kept  from  other  children  for  three  weeks,  the 

incubation  period. 

Room. 

Light  and  well  aired. 

Physician. 

Wash  hands  on  leaving  case. 
Avoid  seeing  another  child  at  once. 

Patient. 
Should  go  to  bed,  if  there  is  fever  or  malaise;  otherwise,  not  necessary. 

Bath. 

Cannot  be  given  when  the  eruption  is  abundant  as  the  vesicles  may 
break  and  become  infected. 

Diet. 

There  need  be  little  change  from  the  usual  unless  there  is  fever; 

then  exclude  solids. 
Water  should  be  given  freely. 

Skin. 

Danger  of  scarring  on  the  face. 
Keep  eruption  dry. 
Use  sterile  talcum  powder  or 

3 

starch 

zinc  oxide  \  equal  parts, 
boric  acid  J 

To  keep  young  children  from  scratching  and  infecting,  put  card- 
board splints  around  the  arms  at  the  elbows,  or  wrap  the  hands 
in  gauze,  or  cut  the  nails  short. 

Treatment  of  pustules. 

Evacuate  by  incising  edge  of  pustules  with  small  lancet  or  Hagedorn 

needle.    Gently  syringe  out  pus. 
Irrigate  the  bad  ones  with  a  fine  pointed  dropper,  using  boric  acid 

solution,  or 
Peroxide  of  hydrogen,  quarter  to  half  strength. 

Itching. 

Bicarbonate  of  soda  solution. 

Phenol,  1  per  cent,  to  5  per  cent,  hi  olive  oil  or  vaseline. 
If  severe,  10  per  cent,  over  a  limited  area. 
Bethea  recommends: 


VARICELLA  519 


Phenolis  ...............................................  gr.  v 

or 
Camphorae  .............................................  gr.  xv 

M.  et.  adde. 

Hydrg.  Ammon  ..........................................  gr.  xv 

Ung.  Sulphuris  q.  s.  ad  ...................................  5  l 

Stomatitis. 

Mouth  cleansed  after  each  feeding  with 
Physiological  salt  solution  3i  to  Oi  (4  Gm.  to  500  c.c.)  or 
Dobell's  solution,  half  strength,  or  boric  acid  solution,  2  per  cent,  to 

4  per  cent. 
(See  Measles,  Chap.  XIX.) 

Bowels. 

When  first  seen  a  mild  saline  of  milk  of  magnesia  3ii  to  iv  (8-15  c.c.) 
or  liquor  magnesii  citratis  3iv  to  viii  (120-240  c.c.). 

Fever. 

Cold  water  dabbed  on  skin. 
Cold  air. 

Nervous  symptoms. 
Usually  due  to  itching. 
Apply  sedatives  to  the  skin  (see  above). 

Bromides  gr.  v  to  x  (0.30-0.60  Gm.)  according  to  age,  every  four 
to  six  hours. 

Complications. 
Stomatitis. 

(See  Measles,  Chap.  XIX.) 
Conjunctivitis. 

(See  Measles,  Chap.  XIX.) 

Corneal  ulcer. 

1  per  cent,  atropine  sulphate. 
Powdered  dionin. 

5  per  cent,  yellow  oxide  of  mercury. 
Nephritis. 

(See  Scarlet  Fever,  Chap.  XVII.) 
Herpes  Zoster.     Protection  against  infection.     (See  text.) 

Convalescence. 
Fresh  air. 
Abundant  food. 

Iron,  i.  e.,  bitter  wine  of  iron  (vinum  ferri  amarum)  3i-ii  (4-8  c.c.) 
three  times  a  day  after  meals. 

Release  from  quarantine. 

When  the  last  scab  has  come  off  . 
Give  a  cleansing  bath  and  a  shampoo. 

Disinfection. 
Clean  and  air  the  room. 


CHAPTER  XXII 

PERTUSSIS 

(WHOOPING  COUGH) 

BY  the  layman  whooping  cough  is  looked  upon  as  a  disease  of  lesser 
significance,  an  annoying  inconvenience  rather  than  a  danger;  by  the 
physician  in  general,  in  spite  of  the  statistical  evidence  of  its  high  mor- 
tality, its  gravity  is  not  duly  appreciated.  Measles  and  whooping  cough 
are  exceedingly  dangerous  diseases  when  attacking  young  children  under 
two  years,  but  the  low  mortality  among  the  older  children  seems  to 
determine  the  attitude  of  the  public  to  the  disease  in  general.  Adults 
are  immune  only  by  virtue  of  a  previous  attack. 

Whooping  cough  is  highly  contagious;  few  children  exposed  to  it 
escape  the  infection  and  the  incidence  of  the  disease  among  the  very 
young,  six  months  and  under,  a  period  which  seems  to  enjoy  a  relative 
immunity  to  many  of  the  other  infections  of  childhood  together  with 
the  frequency  of  bronchopneumonia  of  severe  grade  and  the  difficulty 
of  feeding  when  vomiting  is  frequent,  makes  it  a  disease  to  be  dreaded 
and  by  every  possible  means  averted. 

The  mortality  under  one  year  is  said  to  be  about  25  per  cent. 

Unfortunately,  the  very  period  during  which  it  is  most  contagious 
is  that  in  which  it  displays  nothing  characteristic  to  afford  a  warning  of 
its  real  nature  and  permit  of  avoidance,  for  in  the  early  or  catarrhal 
stage,  it  is  looked  upon  as  a  coryza  and  a  tracheitis  or  bronchitis,  until 
the  persistency  of  the  cough,  its  periodicity,  its  paroxysmal  character  or 
the  vomiting  accompanying  the  paroxysm  give  the  hint  of  the  real  condi- 
tion, while  the  one  or  two  weeks  of  this  stage  has  offered  abundant 
opportunity  to  infect  all  susceptible  individuals  who  are  in  contact  with 
the  patient.  When  the  paroxysmal  or  whooping  stage  has  arrived  the 
infectivity  has  materially  diminished,  some  good  authorities  think  has 
passed,  though  such  an  opinion  seems  to  me  at  the  present  time  not 
sufficiently  substantiated  to  act  upon.  Probably  three  weeks  corre- 
spond fairly  well  with  the  infectious  period ;  but  six  weeks  for  a  quaran- 
tine are  safer.  The  etiological  agent  is  a  bacillus,  morphologically,  but 
not  culturally  identical  with  the  influenza  bacillus  of  Pfeiffer.  It  was 
described  in  1906  by  Bordet  and  Gengou.  The  incubation  period  is 


PERTUSSIS  521 

variously  given  from  a  few  days  to  a  little  more  than  two  weeks.  Three 
weeks  is  a  safe  figure  for  practical  purposes. 

Symptomatology.  The  course  may  be  divided  into  three  stages: 
first  the  catarrhal  with  symptoms  of  a  "cold,"  tracheitis,  bronchitis, 
cough  and  a  little  fever;  the  cough  arouses  suspicion  by  its  persistency, 
its  relative  severity  at  night,  and  by  a  curious  coughing  down  the  scale 
so  to  speak,  until  the  last  breath  is  exhausted  and  the  face  is  suffused  or 
blue.  This  lasts  about  ten  days.  The  second  period  is  the  spasmodic, 
culminating  in  the  typical  whoop.  It  must  be  remembered,  however, 
that  a  whoop  may  be  absent  throughout ;  another  significant  result  of  the 
paroxysm  of  coughing  is  the  vomiting,  which  has  diagnostic  significance 
even  in  the  absence  of  the  whoop.  The  duration  of  this  period  cannot 
be  definitely  fixed  and  may  last  for  weeks;  though  commonly  the  whole 
course  of  the  disease  is  about  six  weeks.  The  third  period  is  that  of 
decline  of  cough  and  other  symptoms.  It  not  infrequently  happens  that 
paroxysmal  coughing  and  even  a  whoop  will  recur  for  months  on  the 
occasion  of  a  cold  or  irritation  of  the  trachea  or  larynx  that  will  be 
mistaken  for  a  recurrence. 

The  blood  may  show  a  mild  leucocytosis,  up  to  15,000  to  25,000,  and 
the  differential  count  a  relative  increase  in  lymphocytes,  even  up  to 
80  per  cent,  at  times. 

The  most  serious  features  of  the  disease  are  bronchopneumonia  as  a 
complication,  the  malnutrition  incident  on  the  vomiting,  and  tuber- 
culosis as  a  sequel.  Others  will  be  discussed  under  treatment. 

Excellent  results  with  the  complement  fixation  test  reported  by 
the  workers  of  the  New  York  City  Board  of  Health  make  it  urgent  to 
utilize  it,  in  suspected  cases,  when  other  children  are  endangered,  pro- 
vided the  technique  of  the  reaction  can  be  properly  carried  out.  This 
test  seems  to  be  more  reliable  than  the  agglutinin  test.  The  latter  has 
little  or  no  value  after  the  first  week  and  it  is  necessary  that  it  must  be 
positive  in  a  dilution  of  not  less  than  1 :200.  It  is  only  fair  to  add  that 
all  investigations  do  not  agree  about  the  value  of  these  tests. 

Distribution  of  the  Family.  As  has  been  said  the  long  delay 
of  the  diagnostic  symptoms  during  the  most  infectious  stage  makes 
infection  of  other  children  almost  certain  when  whooping  cough  has 
not  been  expected,  but  in  the  presence  of  an  epidemic,  the  first  signs 
of  coryza  or  the  first  cough  should  make  the  individual  a  suspect  and 
measures  for  protection  of  the  other  children  be  taken.  So  serious  is  this 
condition  to  infants  and  to  weakly  children  that  the  attempt  should  be 
made  under  any  circumstances  to  prevent  infection.  The  most  effica- 
cious means  is  by  removing  the  other  children  to  another  house,  unoc- 
cupied by  children  or  if  that  cannot  be  done,  to  endeavor  to  preserve 


522  TREATMENT  OF  ACUTE  INFECTIOUS  DISEASES 

a  quarantine  t>f  the  affected  case  in  the  house.  This  last  is  especially 
difficult,  because  of  the  long  course  of  the  disease  and  because  of  the 
unwisdom  of  cooping  up  in  the  house  the  infected  child,  who  has  no 
complications.  This  quarantine  shorld  last  six  weeks. 

The  children  who  are  removed  from  an  infected  house  become  suspects 
and  must  themselves  be  isolated  until  the  period  of  incubation  of  the 
disease  has  elapsed.  The  incubation  is  usually  set  as  one  to  two  weeks, 
but  to  avoid  the  exceptional  case  these  "contacts"  should  be  isolated 
for  three  weeks. 

The  mode  of  infection  is  by  direct  contact,  the  organism  being  borne 
in  the  fine  spray  of  a  cough  or  sneeze  or  even  in  all  probability  in  the  act 
of  laughing  and  talking.  It  is  to  be  remembered,  however,  that  it  is 
possible  for  a  third  person  to  carry  the  disease,  when  the  conveyance  is 
rapid;  this  is  important  to  remember,  when  the  mother  or  other  person 
in  contact  with  the  patient  may  be  tempted  to  go  from  one  to  the 
other. 

Another  important  fact  to  be  kept  in  mind  is  that  the  infection  can 
undoubtedly  be  conveyed  in  the  open  air  and  realizing  the  carelessness 
of  nurses  and  mothers,  too,  in  taking  the  affected  children  about,  when 
allowed  out,  in  the  presence  of  an  epidemic  young  infants  should  be  kept 
from  gatherings  of  children  and  decidedly  so  if  any  of  them  are  coughing. 

The  prophylactic  use  of  vaccines  hi  children  who  are  exposed  is  now 
generally  appreciated.  See  Prophylaxis. 

Room.  A  large  room  with  the  possibilities  of  light  and  air 
should  be  chosen  or  a  room  opening  off  a  balcony,  verandah  or  even 
fire-escape.  It  is  well  when  the  opportunity  affords  to  select  two  rooms 
opening  into  each  other;  this  to  permit  of  frequent  ventilation,  by 
changing  the  patient  from  one  to  the  other.  It  is  possible  that  the  rooms 
become  so  infected  that  the  patients  reinfeot  themselves,  so  that  disin- 
fection of  the  room  with  a  formaldehyde  candle,  lamp  or  other  contri- 
vance, every  few  days  is  advisable. 

Too  much  fresh  air  one  cannot  have,  but  draughts,  high  winds  and 
dust  are  to  be  avoided. 

Open  air  is  most  desirable,  and  the  patient  can  be  kept  on  the 
balcony  a  good  part  of  the  time,  but  in  the  colder  weather,  the  frequent 
attacks  of  coughing,  that  must  displace  the  coverings,  as  the  child  sits  up, 
makes  it  less  feasible  than  in  other  infections  of  the  bronchial  tree. 
Where  such  exposures  are  frequent  it  is  well  to  keep  the  temperature 
about  70°  F.,  not  allowing  it  to  go  much  below  65°  F.  In  mild  cases 
children  may  be  dressed  and  taken  out  in  the  open  air  in  suitable  weather, 
but  only  when  it  can  be  guaranteed  that  no  contact  with  healthy  children 
may  take  place.  A  change  of  climate  if  a  child  can  travel  and  entail  no 


PERTUSSIS  523 

risk  to  others  is  often  of  great  help ;  especially  from  the  North  in  Winter 
to  a  milder  clime. 

Clothing  should  be  flannel  next-  the  skin  whether  in  bed  or  up 
and  about  to  avoid  the  chill  that  comes  from  wet  clothing  drenched 
with  the  sweats  after  a  paroxysm  and  from  the  frequent  exposures. 

Overclothing,  which  keeps  the  skin  perpetually  moist  and  enhances 
the  possibilities  of  bronchial  involvement  and  burdens  the  chest,  is 
to  be  avoided. 

Those  children  who  are  very  young,  very  weak  or  have  considerable 
bronchitis  have  to  be  watched  with  more  care  in  the  open  air  and  many 
good  men  prefer  to  keep  them  to  the  room  at  an  even  temperature,  with 
frequent  ventilation. 

Nurse.  Considering  how  highly  contagious  the  disease  is  and 
that  adults  as  well  as  children  are  susceptible  to  it,  it  is  hardly  just  to 
ask  a  nurse  to  take  a  case  of  pertussis  unless  she  has  already  had  the 
disease,  for  while  the  danger  to  an  adult  is  minimal,  the  length  of  time 
that  she  would  be  debarred  from  exercising  her  profession  would  work 
an  injustice.  A  nurse  who  is  willing  might  be  given  prophylactic  vac- 
cines. 

The  nurse  should  realize  that  while  rare,  still  direct  conveyance 
of  the  disease  through  the  third  person  is  possible  and  should  avoid 
contact  with  other  children  while  off  duty. 

While  on  duty  the  nurse  should  not  leave  her  patient,  especially 
if  it  is  a  young  child  or  infant,  for  suffocation  may  occur  in  a  paroxysm 
or  a  convulsion  may  ensue. 

Physician.  The  physician  should  avoid  the  small  risk  of  convey- 
ing the  disease  by  wearing  a  gown  and  washing  his  face  and  hands 
on  leaving  the  sick-room.  He  should  not  make  his  next  visit  on  a  child 
unless  some  little  tune  in  the  open  air  intervenes. 

If  he  himself  has  not  had  the  disease,  he  should  be  careful  not  to 
stand  directly  in  front  of  the  patient  during  a  paroxysm,  unless  there 
is  some  special  need.  Perhaps  a  mask,  like  a  chloroform  mask  over  the 
nose  and  mouth,  the  gauze  or  cover  of  which  has  been  wet  with  1  to  20 
carbolic  acid  may  help  in  avoiding  infection.  Vaccine  might  be  used 
prophylactically,  though  the  risk  to  him  is  not  as  great  as  to  the  nurse. 

Precautions  in  the  Sick-Room.  Strict  isolation  to  the  quarters 
assigned  the  patient,  as  long  as  he  is  confined  to  his  room,  and  when  the 
patient  is  permitted  to  go  out  of  doors  careful  avoidance  of  contact  with 
other  children  is  the  rule  to  be  observed. 

All  secretions  are  to  be  received  on  cloths  and  burned  or  into  recep- 
tacles and  sterilized. 

Bed  linen,  night  clothing,  towels  and  so  forth  should  not  be  sent 


524  TREATMENT  OF  ACUTE  INFECTIOUS  DISEASES 

to  the  family  laundry  until  they  have  been  ^boiled  an  hour  separately 
or  allowed  to  soak  overnight  in  1  to  20  carbolic  acid. 

Cats  and  dogs  are  believed  to  carry  the  infection  and  ar^  to  be  ex- 
cluded from  the  sick-room.  Two  children  should  not  be  treated  in 
the  same  room. 

Bed.  For  treatment  in  the  open  air  the  bed  is  made  in  a  special 
manner,  see  Pneumonia,  Chap.  IX. 

All  patients  with  whooping  cough  are  not  to  be  confined  to  bed. 
The  indications  for  remaining  in  bed  are  the  presence  of  a  febrile  reaction 
or  any  serious  complication. 

In  this  disease  the  nerves  are  particularly  affected  and  trivial  excita- 
tion can  precipitate  the  paroxysm;  among  these  the  slight  chill  from 
being  put  into  a  cold  bed. 

Baths.  A  cleansing  bath  should  be  given  every  day  with  soap  and 
tepid  water.  This  may  be  done  on  a  blanket  or  between  the  folds  of  a 
blanket,  exposing  only  one  part  at  a  time. 

Diet.  For  older  patients  with  the  milder  form  of  attack,  who 
are  not  confined  to  the  house,  no  material  change  in  the  diet  need  be 
instituted,  provided,  of  course,  that  the  diet  is  suitable  for  a  child  of 
a  given  age. 

It  is  the  association  of  vomiting  with  the  paroxysms  and  the  gastro- 
intestinal complications  that  may  occur  that  make  feeding  in  whooping 
cough  a  difficult  problem. 

When  there  are  no  serious  complications,  gastro-intestinal  or  pul- 
monary and  the  vomiting  entails  merely  a  loss  of  food  ingested,  the 
deficit  can  be  made  up  by  a  little  tact  and  perseverance. 

After  the  explosion  of  the  paroxysm  of  coughing  with  which  the 
vomiting  is  so  closely  associated,  there  is  a  period  of  quiescence  for 
both  the  organs  of  respiration  and  digestion. 

One  should  take  advantage  of  this  to  offer  food,  so  that  as  large  a 
portion  of  the  meal  as  possible  may  be  digested  and  passed  along  into  the 
intestinal  canal  before  the  next  paroxysm  is  due. 

On  the  other  hand,  as  the  time  for  the  succeeding  paroxysm  draws 
near,  the  ingestion  of  food  excites  the  coughing  reflex  and  precipitates 
the  paroxysm. 

When  the  paroxysms  become  very  frequent,  every  hour  or  every 
half  hour,  no  considerable  period  is  left  between  paroxysms  for  gastric 
digestion ;  then  the  problem  is  to  introduce  such  food  as  requires  a  brief 
stay  in  the  stomach  and  carries  with  it  a  maximum  amount  of  fuel. 

In  early  childhood  and  infancy  the  staple  article  of  diet  is  milk,  plain 
or  modified,  and  when  one  remembers  the  physiology  of  milk  digestion, 
the  precipitation  of  the  curd,  the  digestion  at  the  periphery  and  the 


PERTUSSIS  525 

three  hours  required  for  its  complete  removal  from  the  stomach,  one  sees 
the  benefit  accruing  from  small  quantities  of  milk  taken  frequently,  thus 
affording  the  maximum  surface  for  digestion  and  the  use  of  means  or 
methods  that  lessen  the  bulk  of  the  curds.  Among  these  measures  are 
dilution  with  water,  half  and  half  affording  the  optimum  for  rapidity  of 
digestion,  or  the  use  of  lime  water,  1  in  20  or  the  use  of  a  cereal  water 
barley  or  arrowroot  as  a  diluent  instead  of  plain  water,  or  the  use  of  milk 
gruels,  using  barley,  wheat  flour,  rice,  arrowroot,  or  some  of  the  malted 
or  farinaceous  foods  used  for  infant  feeding,  or  whey,  buttermilk, 
koumys,  or  predigested  milk  or  animal  broths  may  be  given  or  their  food 
value  added  to  by  thickening  with  farinaceous  foods,  custards  baked  or 
soft,  jellies  or  gelatin  carrying  sugar,  junket,  soft  egg  or  albumin  water, 
but  always  in  giving  these  liquid  foods,  some  estimate  must  be  made  of 
the  amount  of  fuel  value  they  represent  in  the  twenty-four  hours,  for  too 
often  is  it  forgotten  that  considerable  bulks  of  liquid  food  may  be 
ingested  that  have  almost  no  energy  value,  for  example,  animal  soup 
and  broths. 

Wet  toast,  milk  toast  or  softened  rusks,  boiled  rice  and  cereals  with 
milk  and  cream  or  sugar  may  be  added.  No  dry  food  should  be  given, 
lest  the  articles  irritating  the  pharynx  precipitate  the  attack  of  cough- 
ing. 

In  infants  on  milk  mixtures,  the  dilutions  should  be  increased,  and  the 
feedings  made  in  smaller  amounts  at  more  frequent  intervals. 

In  the  worst  cases  with  gastro-intestinal  indigestion,  every  effort 
is  set  at  naught  and  one  has  recourse  to  rectal  feeding,  but  with  small 
hope  that  it  will  be  borne  sufficiently  long  or  be  attended  with  sufficient 
success  to  more  than  meet  short-lived  emergencies. 

Care  of  the  Patient.  In  the  lighter  cases,  going  out  of  doors, 
only  the  daily  bath  in  the  morning,  flannel  next  the  skin,  taking  care  not 
to  overclothe,  ordinary  oral  hygiene  and  cleansing  the  nose  with  sprays 
of  boric  acid  solution  2  per  cent,  or  DobelTs  solution  quarter  strength  or 
with  the  same  applied  on  a  swab  of  cotton,  with  destruction  of  the 
secretions  during  the  catarrhal  stage,  are  all  the  measures  indicated. 
When  serious  complications  of  the  respiratory  tract  or  of  the  alimentary 
tract  ensue,  the  care  of  the  mouth  is  of  great  importance. 

Bowels.  Unless  there  are  complications  the  bowels  are  to  be 
kept  open  with  mild  cathartics,  such  as  cascara  in  the  older  children 
and  milk  of  magnesia  in  the  younger. 

Fever.  The  fever  in  uncomplicated  cases  is  so  trivial  as  to  require 
no  treatment;  it  is,  however,  an  indication  for  keeping  the  patient 
confined  to  the  bed. 

Cough.      The    paroxysmal   cough   is    the   characteristic    symptom 


526  TREATMENT  OF  ACUTE  INFECTIOUS  DISEASES 

of  pertussis.  The  frequency  and  severity  of  th.ese  paroxysms  deter- 
mine in  no  small  measure  the  prognosis  in  the  disease. 

Not  only  is  the  cough  in  itself  exhausting,  but  in  the  severe. cases 
it  may  be  responsible  for  suffocation,  convulsions  or  cerebral  hemor- 
rhages. More  than  this  it  is  accompanied  by  vomiting,  so  frequent 
at  times  that  it  is  absolutely  incompatible  with  adequate  nutrition  and 
in  the  very  young  and  weakly  is  the  lethal  factor. 

Efforts  in  the  treatment  of  whooping  cough  are  largely  directed  to  the 
diminution  of  the  number  of  paroxysms,  to  afford  rest  and  make  possible 
a  sufficient  feeding. 

If  vaccines  are  of  value  then*  early  use  is  obviously  indicated  to  ame- 
liorate this  symptom. 

There  is  no  reason  to  believe  that  any  of  the  empirical  measures 
used  heretofore  shorten  the  disease;  they  merely  ameliorate  the  condition 
of  the  patient;  hence,  if  the  disease  is  mild  and  the  paroxysms  relatively 
infrequent,  no  treatment  should  be  given  other  than  that  determined  by 
the  hygienic  and  dietetic  measures  already  laid  down. 

If  we  can  avoid  drugs  we  should  do  so,  for  it  must  always  be  remem- 
bered that  a  drug  does  many  things  to  the  organism  besides  that  which 
we  particularly  desire  and  some  of  these  drug  effects  are  deleterious,  as 
for  example,  the  disturbance  of  digestion  in  a  disease  in  which  so  much 
depends  on  the  stomach.  In  cases  of  moderate  severity  we  may,  then, 
with  advantage,  see  what  local  measures  effect  before  having  recourse 
to  medication. 

LOCAL    PROCEDURES 

Mechanical  Support.  Few  simple  devices  have  been  rewarded 
with  more  success  than  the  one  recommended  by  Kilmer,  the  appli- 
cation of  an  elastic  belt  to  the  abdomen,  chest  or  both. 

The  support  given  by  this  contrivance  lessens  the  vomiting  in  no 
small  measure  and  modifies  the  frequency  of  the  paroxysm.  It  finds 
its  greatest  application  in  infants  and  weakly  children  with  poor  abdom- 
inal tone,  such  as  obtains  in  rickets.  Kilmer's  instructions  are  as  follows : 
"A  stockinette  band  is  placed  upon  a  baby  ...  in  the  same  manner  as 
is  done  by  orthopedists  before  applying  the  plaster-of-Paris  jacket.  This 
band  extends  from  the  axilla  to  the  pubes  and  fits  the  baby  snugly.  Two 
shoulder  straps  are  used  to  prevent  the  band  from  slipping  down.  Upon 
this  stockinette  band  a  single  width  of  elastic  bandage  is  sewn,  extending 
entirely  around  the  body  and  covering  the  abdomen.  The  bandage  is 
sewn  on  when  very  slightly  on  the  stretch."  If  the  vomiting  is  not  con- 
trolled the  belt  may  require  a  little  tightening.  The  effect  is  particularly 
noticeable  on  the  vomiting.  A  similar  elastic  bandage  may  be  sewed  on 


PERTUSSIS  527 

the  stockinette  to  cover  the  chest  and  diminishes  the  number  of  par- 
oxysms. These  may  be  worn  separately  or  together.1 

All  forms  of  excitement  and  highly  emotional  states  should  be  avoided ; 
gentle  persuasion  in  nervous  children  exerted,  which  while  it  cannot 
abort  a  true  paroxysm,  may  lessen  the  cough  often  suggested  to  the 
child  which  precipitates  a  paroxysm.  Fresh  air,  avoidance  of  dust, 
prevention  of  chilling  by  exposure  to  draughts,  cold  beds,  etc.,  constitute 
no  mean  part  of  the  treatment. 

Numerous  sprays,  local  applications  to  the  air  passages  and  insuffla- 
tions have  been  advised.  They  are  of  more  than  doubtful  efficacy,  while 
they  often  excite  and  alarm  the  child  and  aggravate  the  condition. 

Inhalations.  Inhalations  of  medicated  steam  will  sometimes  lessen 
the  number  and  severity  of  the  paroxysms  and  lessen  the  cough  of 
bronchitis,  occurring  between  the  paroxysms  or  render  more  liquid  and 
easy  of  discharge  the  mucus  of  a  bronchitis. 

It  must  be  remembered  that  fresh  air  is  of  first  importance  in  whoop- 
ing cough  and  that  it  should  not  be  sacrificed  to  long  inhalations,  which 
themselves  from  the  heat  and  dampness  may  become  depressing. 

Again  it  must  be  remembered  that  one  case  may  find  more  relief 
from  one  agent  than  from  another,  or  that  better  results  are  afforded 
by  occasional  change  of  the  medicament  employed. 

One  may  try  the  compound  tincture  of  benzoin  first,  three  or  four 
times  a  day,  more  especially  at  night,  when  the  paroxysms  are  likely  to 
be  worse  and  sacrifice  sleep,  or  the  frequency  and  length  of  time  may  be 
determined  by  the  degree  of  relief  afforded. 

A  dram  or  two  of  compound  tincture  of  benzoin  is  placed  upon  the 
surface  of  hot  water;  the  drug  is  carried  with  the  steam  and  inhaled. 

Simple  devices  may  be  used,  such  as  a  pitcher,  a  carafe,  or  a  simple 
kettle  to  contain  the  hot  water,  a  cone  of  paper  arranged  over  the  mouths 
of  the  vessels  or  the  spout  of  the  kettle.  If  the  latter  is  used,  it  may  be 
kept  steaming  and  a  rubber  tube  attached  to  the  spout  may  be  attached 
at  the  other  end  of  a  funnel,  to  facilitate  the  inhalation. 

Another  simple  device  that  is  especially  applicable  to  children  is  as 
follows: — the  child  lies  on  the  side  of  the  bed,  a  pitcher  filled  with  boiling 
water,  to  which  the  medication  is  added,  is  placed  on  the  floor  on  a  level 
lower  than  the  face,  a  stiff  piece  of  cardboard,  previously  warmed  to 
lessen  condensation  of  the  steam,  is  bent  into  the  shape  of  a  half  cylinder 
and,  as  an  inverted  trough,  conducts  the  steam  from  the  pitcher  to 
the  face. 

Croup  kettles  of  various  designs  may  be  used,  but  one  must  always 

1  "Whooping  Cough— A  New  Method  of  Treatment."  Theron  W.  Kilmer. 
New  York  Medical  Journal,  June  20,  1903. 


528  TREATMENT  OF  ACUTE  INFECTIOUS  DISEASES 

be  on  the  sharp  lookout  for  fire  when  the  alcoholjamp  is  used.  Electric 
heaters  are  of  course  to  be  preferred  when  accessible.  Of  the  different 
designs  of  croup  kettle  my  choice  is  for  one  made  by  Lewis  and  Conger  of 
New  York  on  designs  of  Holt.  It  adds  safety  to  convenience. 

The  inhalations  are  altogether  more  efficacious  if  given  under  a  tent 
There  are  numerous  ways  of  contriving  this;  ropes  or  bandages  about  the 
four  posts  of  the  bed,  or  where  posts  are  lacking  improvised  posts  at  the 
corners  of  laths  or  canes,  over  which  a  sheet  may  be  thrown.  A  sheet 
may  be  thrown  over  an  open  umbrella.  It  is  better  that  the  whole  body 
should  not  be  included  in  the  tent,  only  the  head.  This  can  be  done  by 
arranging  four  improvised  posts,  two  on  each  side,  a  little  way  apart, 
connected  by  rope  or  bandage  with  a  sheet  or  rubber  sheet  over  them. 

Next  to  benzoin  try  creosote.  This  may  be  given  in  the  same  way; 
a  dram  on  the  surface  of  the  hot  water  used  in  any  of  the  receptacles 
mentioned,  in  the  way  mentioned.  In  some  of  the  croup  kettles,  such  as 
Holt's,  a  sponge  carried  in  the  spout  receives  the  creosote  and  the  steam 
passing  through  the  sponge  conveys  the  vapor  of  the  drug. 

A  mixture  of  creosote  (3ii)  (8  c.c)  and  compound  tincture  of  benzoin 
(5ii)  (60  c.c.)  affords  a  good  combination. 

Chloroform.  When  the  paroxysms  are  frequent  or  severe,  threat- 
ening convulsions,  or  asphyxia,  a  few  drops  of  chloroform  on  a  handker- 
chief, sponge,  towel  or  the  hand  should  be  given  to  inhale. 

Other  Measures  Advised.  Nagele  has  advocated  pulling  the 
jaw  down  and  forwards,  after  the  manner  of  the  anaesthetists,  to 
interrupt  the  laryngeal  spasm. 

Smith,  quoted  by  Ker,  says  that  prolonged  spasm  may  be  broken 
by  plunging  the  infant's  hands  into  cold  water. 

In  the  most  severe  form  of  spasm,  intubation  may  be  necessary  and 
does  afford  relief.  For  technique  see  Diphtheria,  Chap.  XVIII. 

For  inhalation  one  may  try  oil  of  eucalpytus,  in  the  same  propor- 
tions as  the  benzoin,  or  menthol  gr.  xv  in  3i  to  ii  (1  Gm.  in  4r-S  c.c.)  of 
compound  tincture  of  benzoin  as  recommended  by  Holt,  or  cresolin,  two 
or  three  times  in  the  twenty-four  hours.  There  is  on  the  market  a  special 
form  of  vaporizer  for  cresolin. 

Drugs.  No  end  of  drugs  have  been  recommended  to  relieve  the 
paroxysms  of  pertussis,  which  in  itself  constitutes  the  proof  of  their 
very  limited  value. 

The  condition  to  be  attacked  is  a  hyperexcitability  of  the  neuromus- 
cular  apparatus  of  the  larynx,  as  well  as  a  general  nerve  excitation.  It 
would  seem  rational,  then,  to  select  drugs  that  have  a  sedative  effect  on 
the  nervous  system  and  those  are  the  drugs  that  have  been  shown 
empirically  to  be  the  most  efficacious.  It  must  be  remembered,  however, 


PERTUSSIS  529 

that  these  drugs  all  have  undesirable  effects  as  well,  the  most  of  them 
being  depressant  to  the  circulation  and  so  should  not  be  used  indefinitely 
or  recklessly.  Again  it  is  to  be  remembered  that  individuals  react 
differently  to  the  different  drugs  and  if  results  are  not  obtained  after  full 
dosage,  it  is  better  to  try  another  rather  than  keep  on  with  the  first  in 
hopes  that  the  action  is  merely  delayed. 

My  own  preference  is  for  the  drug  especially  advocated  by  Holt 
and  now  used  very  extensively,  antipyrin. 

Antipyrin.  This  drug  is  easily  soluble  in  water  and  has  a  slightly 
bitter  taste,  but  hardly  enough  to  make  it  desirable  to  disguise  the 
taste.  It  should  be  given  in  liberal  quantities. 

Holt  advises  for  a  child  six  months  old  gr.  i  (0.060  Gm.)  every  three 
hours  and,  if  there  are  no  untoward  symptoms  increase  the  dosage  up  to 
every  two  hours.  At  a  year  one  may  begin  with  a  grain  and  a  half 
(0.10  Gm.)  and  at  two  years  gr.  ii  (0.125  Gm.)  every  four  to  six  hours, 
the  dosage  being  increased  up  to  every  two  hours. 

As  the  paroxysms  are  as  a  rule  worse  at  night,  one  can  with  advantage 
combine  with  the  antipyrin  sodium  bromide,  in  doses  of  gr.  ii  (0.125  Gm.) 
at  six  months,  gr.  iii  (0.20  Gm.)  at  one  year  and  gr.  iv  (0.25  Gm.)  at  two 
years  to  be  administered  in  the  latter  part  of  the  day  and  night. 

By  some  it  is  deemed  advisable  to  stop  the  drug  after  a  week,  having 
recourse  to  some  other  drug,  as  bromide  for  a  few  days,  alternating  by 
periods  with  antipyrin. 

The  drug  is  contraindicated  in  weakly  children  with  impaired  circu- 
lation or  with  pneumonia. 

Bad  effects  rarely  come  from  such  dosage  as  is  advised  unless  the 
patient  has  an  idiosyncrasy  for  the  drug. 

The  most  common  idiosyncrasy  is  marked  by  an  erythematous  erup- 
tion or  localized  edema.  More  rarely  one  sees  evidences  of  collapse, 
pallor,  weak  pulse,  low  temperature  and  cyanosis,  but  this  is  less  common 
and  less  marked  than  after  acetanilid. 

The  continuance  of  the  drug  must  depend  on  results  and  the  reaction 
of  the  child  to  the  drug. 

Belladonna.  No  drug  has  enjoyed  a  reputation  for  efficiency  in 
pertussis  comparable  with  belladonna.  Belladonna  is  ranked  as  an 
antispasmodic  and  its  pharmacology  is  sufficiently  worked  out  to  justify 
this  classification.  Its  effects  on  motor  nerve  endings  supplying 
smooth  muscle  structures  explains  its  good  effects  in  many  forms  of 
spasm,  but  will  not  explain  the  results  obtained  in  the  spasm  of  the 
striped  muscles  of  the  larynx.  Pharmacologists  have  not  adequately 
explained  its  clinical  results  in  this  disease. 

Cushny  has  suggested  that  perhaps  it  owes  its  efficacy  to  its  content 


530  TREATMENT  OF  ACUTE  INFECTIOUS  DISEASES 

of  hyoscine  operating  to  depress  the  irritability  of  ,the  respiratory  center. 
If  this  is  true,  one  would  not  substitute  atropine  for  the  Galenical  prep- 
arations of  the  drug.  It  is  possible  that  a  depression  of  sensory,  nerve 
endings  in  the  mucous  membrane  of  the  trachea  affected  may  play  a  role. 

Two  facts  must  be  kept  in  mind  in  using  the  drug  to  control  the 
paroxysms.  (1)  That  it  has  to  be  used  to  the  physiological  limit,  that  is, 
to  the  point  of  the  earliest  toxic  manifestation  to  get  results;  and  (2)  that 
there  are  many  individuals  that  have  an  idiosyncrasy  for  this  drug; 
hence,  the  beginning  dose  must  be  small,  a  tentative  dose. 

The  most  consistent  advocate  of  this  treatment  was  Jacobi,  whose 
definite  instructions  in  the  usage  of  this  drug  in  his  editor's  note  to 
the  article  on  Pertussis  in  Modern  Clinical  Medicine  cannot  be  improved 
upon  and  which  I  quote  here. 

Taking  the  case  of  a  child  of  two  years,  he  says,  "Give  6  drops  of 
Tr.  Belladonna  three  times  a  day;  unless  the  drug  cause  a  'feverish'  flush 
on  the  cheeks  within  half  an  hour,  which  must  last  half  an  hour  or  more, 
it  has  no  effect.  If  6  drops  have  no  such  effect,  give  7,  8,  9  or  more  every 
time.  The  effect  must  be  attained  every  time,  three  times  daily.  Give 
as  many  drops  as  are  required  to  accomplish  that  end.  After  a  few  days 
more  drops  will  be  required.  After  about  a  week  the  full  dose  will  prob- 
ably have  to  be  doubled." 

I  would  advise  before  starting  with  so  large  a  dose  as  advised  by 
Jacobi  that  a  small  dose  of  m.  i  (0.060  c.c.)  of  the  Tincture  be  used,  for 
in  cases  of  idiosyncrasy  the  susceptibility  is  demonstrated  to  small  doses. 
If  there  are  no  untoward  effects  one  may  rapidly  mount  to  the  dose 
advised. 

If  there  be  no  idiosyncrasy  one  feels  free  to  give  large  doses,  for  this 
is  one  of  the  drugs  that  children  bear  proportionately  better  than  adults, 
taking  as  J.  Walter  Carr  says  at  four  or  five  years  as  large  doses  as  adults. 

One  may  give  doses  at  more  frequent  intervals,  every  four  hours, 
if  preferred,  but  when  the  full  dose  is  attained,  to  the  production  of 
flushing  with  its  attendant  disagreeable  manifestations,  I  think  the 
fewer  doses  are  to  be  preferred. 

If  we  are  treating  an  infant  of  six  months,  one  begins  with  a  dose 
of  m.  ss.  to  i  (0.006  c.c.)  three  times  a  day  or  the  fluid  extract  m.  1/10 
(0.006  c.c.),  at  one  year  double  the  dose,  at  two  years  begin  with  m.  iii 
(0.20  c.c.)  of  tincture  and  increase  a  minim  (0.060  c.c.)  a  dose  every  day 
to  "flushing." 

Beside  the  flushing  one  may  anticipate  dryness  of  the  mouth,  some 
hoarseness  and  dilated  pupils. 

Idiosyncrasies  for  the  drug  are  shown  both  by  the  symptoms 
just  specified  occurring  with  a  minimum  dose  or  by  a  general  erythema, 


PERTUSSIS  531 

suggesting  scarlet  fever,  a  talkative  delirium  and  more  rarely  by  vomiting 
and  prostration. 

If  the  delirium  is  wild  it  may  be  controlled  by  morphine,  while  prostra- 
tion or  collapse  may  be  combated  by  caffeine,  camphor  and  strychnine. 
The  bladder  should  be  emptied  by  catheterization,  if  retention  occurs, 
and  in  severe  cases  saline  infusions  help  to  encourage  diuresis  and 
elimination. 

Bromides.  These  drugs  are  hardly  potent  enough  to  be  of  much 
avail  unless  pushed  to  a  point  of  general  depression,  but  combined  with 
antipyrin  may  enhance  the  sedative  effect  of  the  latter.  They  may  be 
used  with  the  antipyrin  in  the  latter  part  of  the  day  and  more  especially 
when  there  is  much  insomnia.  The  dose  for  a  child  of  two  should  be  gr.  iii 
(0.20  Gm.)  with  each  dose  of  the  antipyrin  used. 

Some  authors  recommend,  however,  that  they  be  used  alternately 
a  week  at  a  time. 

Opium  and  Its  Derivatives.  The  efficiency  of  opium  in  lessening 
cough,  and  in  inducing  sleep  sorely  tempts  the  physician  and  the 
parent  to  an  unwise  usage.  It  must  be  remembered  that  the  disease  is 
to  be  long  drawn  out,  that  a  certain  degree  of  tolerance  will  be  established 
and  that  children  are  highly  susceptible  to  its  toxic  effects.  For  all  these 
reasons  it  should  be  used  sparingly  and  only  when  imperative,  that  is, 
when  the  other  sedatives  specified  are  without  effect  and  danger  threat- 
ens from  the  exhaustion  induced  by  the  paroxysms. 

Of  opium  itself,  the  best  preparations  are  Dover's  powder  and  pare- 
goric (Tr.  opii  camphorata).  Of  its  derivatives,  codeine  and  heroine. 

Reserve  their  usage  for  the  severe  cases  or  confine  the  dosage  to 
night  administration. 

Try  first  the  effect  of  the  least  harmful  of  these  preparations,  codeine. 
It  may  be  given  in  solution  as  the  phosphate  or  in  tablet  form  to  the 
older  children  as  sulphate,  the  dose  being  gr.  1/100  (0.0006  Gm.)  at  six 
months,  gr.  1/60  (0.001  Gm.)  at  one  year,  gr.  1/40  (0.0015  Gm.)  at  two 
years  up  to  gr.  1/8  (0.008  Gm.)  or  gr.  1/4  (0.015  Gm.)  in  the  older  chil- 
dren. 

Of  the  paregoric  m.  iii-iv  (0.20-0.25  c.c.)  at  six  months,  m.  v-x  (0.30- 
0.60  c.c.)  at  one  year,  m.  x-xx  (0.60-1.30  c.c.)  at  two  years  up  to  3ss. 
(2  c.c.)  at  five  years. 

Of  the  Dover's  powder  gr.  1/8  (0.008  Gm.)  at  six  months, 
gr.  ss.  (0.030  Gm.)  at  one  year,  gr.  i  at  two  years  and  gr.  ii  (0.125  Gm.) 
at  five  years. 

Talbot  with  due  warning  of  possible  danger  entailed,  urges  the 
necessity  of  adequate  doses  of  opium  in  cases  threatened  with  exhaus- 
tion, even  to  the  point  of  producing  prolonged  sleep. 


532  TREATMENT  OF  ACUTE  INFECTIOUS  DISEASES 

These  drugs  are  best  administered  at  bedtime  and  in  severe  cases  may 
be  administered  again  during  the  night. 

MEASURES  RECOMMENDED   BY   OTHER  AUTHORITY 

Quinine.  This  drug  has  long  been  in  use  in  pertussis.  The  gen- 
eral instructions  are  to  administer  it  late  in  the  disease  and  then  in 
large  doses  of  gr.  i  to  gr.  iss.  (0.060-0.10  Gm.)  for  every  year  of  the 
child's  life,  two  to  four  times  a  day.  It  is  hard  to  see  what  benefits  can 
accrue  so  late  in  the  disease  to  offset  the  discomforts  or  possible  toxic 
effects  of  so  large  dosage. 

Heroine.  A  derivative  of  morphine,  is  preferred  by  some  men  to 
codeine.  The  dose  of  the  hydrochloride  is  gr.  1/100  (0.0006  Gm.)  at  one 
year,  to  gr.  1/24  (0.003  Gm.)  four  to  six  times  a  day  or  to  be  used  at  night 
as  codeine  or  opium. 

Many  other  drugs  have  been  recommended,  the  only  excuse  for  using 
which  lies  in  the  fact  that  when  the  more  tried  measures  fail,  one  feels 
justified  in  using  any  means  that  holds  out  any  promise  whatsoever. 

Bromoform  has  had  considerable  vogue,  but  it  is  the  consensus 
of  opinion  that  little  is  to  be  expected  from  it,  while  toxic  manifestations 
are  readily  elicited.  To  children  old  enough  it  may  be  given  dropped  on  a 
lump  of  sugar.  If  not  so,  it  is  best  given  in  emulsion,  but  it  must  be 
remembered  that  it  easily  settles  out  of  the  emulsion;  hence,  thorough 
shaking  must  precede  its  usage  each  time,  and  it  is  well  to  have  a  fresh 
emulsion  made  before  the  bottle  is  exhausted,  to  avoid  the  large  dose  that 
is  almost  sure  to  result  in  the  bottom  of  the  bottle  from  this  fact.  The 
dose  is  a  1/2  minim  to  5  minims  (0.030-0.30  c.c.)  three  times  a  day. 
It  must  be  used  with  caution.  Personally,  I  prefer  not  to  use  it. 

Fluoform,  in  2  per  cent,  solution  in  water  in  doses  of  3i  (4  c.c.) 
of  the  solution  every  two  hours  has  been  recommended. 

Another  fluorine  compound  is  a  difluordiphenyl;  it  is  used  locally 
on  the  chest  in  the  shape  of  an  ointment.  This  is  known  as  antitussin. 
I  have  had  no  experience  with  these  preparations. 

Benzyl  benzoate  is  highly  recommended  by  A.  W.  Bingham  of 
New  York  in  doses  of  20  drops  of  the  20  per  cent,  solution  given  in  milk 
at  three-hour  intervals.  This  dose  is  suitable  for  children  as  young  as  two 
years.  Corresponding  doses  are  given  in  infants. 

Specific  Treatment.  Specific  treatment  by  the  use  of  sera  and 
vaccines  awaits  upon  the  certain  identification  of  the  etiological  agent. 
This  certain  identification  has  not  come,  but  the  claim  of  Bordet  and 
Gengou  that  they  have  isolated  the  bacillus  responsible  for  the  disease 
seems  so  good,  that  this  organism,  isolated  from  the  bronchial  mucus 


PERTUSSIS  533 

raised  by  the  paroxysm  in  the  earlier  stages  of  the  disease,  has  been 
utilized  for  the  production  of  a  vaccine. 

Although  vaccines  have  been  used  extensively  in  the  past  five  years 
since  the  first  edition  of  this  book  there  is  not  yet  an  agreement  as  to 
their  value;  but  I  think  that  many  excellent  pediatricians  look  with  favor 
upon  their  use  and  as  no  bad  results,  genreal  or  local,  have  attended 
the  treatment  so  far,  I  should  be  inclined  to  use  the  treatment. 

Talbot  gives  an  injection  every  other  day  for  three  or  four  doses;  first 
dose  1,000,000,000;  second  dose  1,500,000,000;  third  dose  2,000,000,000; 
fourth  dose  2,000,000,000.  This  dose  is  for  children  two  years  or  over. 
For  children  under  two  years  half  that  dose.  The  Department  of  Health 
of  the  city  of  New  York  recommends  for  children  under  one  year  an 
initial  dose  of  250,000,000  followed  by  500,000,000,  1,000,000,000  and 
2,000,000,000  and  2,000,000,000  at  intervals  of  two  to  three  days.  An 
autogenous  vaccine  may  be  used,  if  the  organism  is  recovered,  but  in 
most  instances  one  has  recourse  to  commercial  products.  Huenekens 
emphasizes  that  the  vaccine  should  be  very  fresh,  not  more  than  a  week 
old  and  no  preservative  be  used. 

Various  sera  have  been  tried  without  encouraging  results. 

Insomnia.  Sleeplessness  is  so  much  the  result  of  the  frequency 
of  the  paroxysms  that  measures  that  relieve  the  latter  improve  the 
former.  The  doses  of  bromides  advised  towards  the  latter  part  of  the 
day  either  in  combination  with  the  antipyrin  or  alone  gr.  iii  (0.20  Gm.) 
are  helpful. 

Chloral  is  well  borne  by  the  child  and  it  may  be  administered 
at  night  in  doses  of  gr.  ii  (0.12  Gm.)  at  six  months,  gr.  iii  or  gr.  iv  (0.20- 
0.25  Gm.)  at  one  year  and  if  not  efficacious  the  dose  may  be  repeated  in 
two  hours.  It  is  somewhat  irritating  to  the  stomach;  hence,  it  may  be 
given  by  the  rectum  in  a  couple  of  ounces  of  warm  milk. 

Trional  has  also  been  used  for  the  purpose,  gr.  ii  to  gr.  iv  (0.12-0.25 
Gm.)  at  two  years  to  be  repeated  if  needed. 

Threatened  exhaustion  from  loss  of  sleep  may  make  the  use  of  opium 
imperative  in  cases  specified  above. 

Complications.  Vomiting  regularly  accompanies  the  disease,  but 
may  become  so  persistent  and  severe  as  to  constitute  a  complication. 

The  first  consideration  is  that  of  the  diet  which  has  already  been 
discussed  under  that  heading. 

The  application  of  the  abdominal  support,  such  as  the  Kilmer  belt,  in 
many  instances  lessens  the  severity  and  frequency  of  the  vomiting  in  no 
small  measure.  (See  mechanical  support  described  above.) 

When  the  vomiting  occurs  with  the  paroxysms,  those  measures  which 
lessen  the  attacks  of  coughing  will  diminish  the  vomiting,  but  at  times 


534  TREATMENT  OF  ACUTE  INFECTIOUS  DISEASES 

the  vomiting  may  occur  apart  from  the  paroxysms,  as  an  expression  of 
gastric  irritation.  In  these  cases,  small  doses  of  bicarbonate  of  soda, 
gr.  v  (0.30  Gm.)  with  the  food  may  be  helpful,  while  in  the  more  severe 
cases  cocaine  hydrochloride,  in  doses  of  gr.  1/6  (0.010  Gm.)  twice  a  day 
has  been  recommended.  (Eustace  Smith  quoted  by  Ker.) 

Diarrhea  is  to  be  treated  by  a  consideration  of  the  diet,  an  occa- 
sional dose  of  calomel  in  divided  doses,  gr.  1/10  (0.006  Gm.)  every  ten 
minutes  for  10  doses  or  gr.  1/4  (0.015  Gm.)  every  1/4  hour  for  4  doses, 
followed  by  bismuth  subnitrate,  gr.  xx  to  gr.  xxx  (1.30-2  Gm.)  every 
three  or  four  hours  and  by  occasional  irrigations.  The  small  doses  of 
calomel  act,  too,  as  an  antiemetic. 

Ulcer  of  the  Frenurn.  An  ulcer  of  the  frenum  of  the  tongue 
occurs  now  and  then  in  whooping  cough.  It  is  usually  superficial  but 
may  be  deep.  It  is  due  to  the  projection  of  the  under  surface  of  the 
tongue  upon  the  cutting  edge  of  the  incisors. 

Efforts  at  healing  are  made  by  boric  acid  mouth  washes  and  occasion- 
ally touching  the  ulcer  with  silver  nitrate  stick. 

If  it  resists  we  may  call  dental  aid  to  protect  the  tongue  against  the 
teeth  or  if  the  process  is  serious  sacrifice  the  teeth,  which,  of  course, 
are  first  teeth. 

Hemorrhages.  These  occur  in  various  parts  of  the  body,  but 
require  no  treatment  (or  expectant  or  symptomatic  treatment  in  case 
of  cerebral  hemorrhage),  except  nasal  hemorrhages.  These  at  times 
may  be  sufficiently  severe  to  require  the  application  of  adrenalin,  in  a 
spray  of  1  to  10,000  or  if  the  bleeding  point  can  be  seen,  on  a  pledget 
of  cotton,  1  to  1,000. 

Very  rarely  the  nares  may  require  plugging. 

Coakley  advises  as  a  hemostatic  tannic  acid,  mixed  with  water  to 
the  consistency  of  a  syrup  and  applied  on  a  pledget  of  gauze. 

Bronchopneumonia.  This  complication  is  what  makes  whooping 
cough  the  serious  disease  it  is.  It  is  responsible  for  the  vast  majority 
of  the  fatal  cases,  estimated  by  some  authorities  at  90  per  cent.  It  is 
prone  to  occur  after  the  paroxysmal  stage  is  well  established,  in  the 
second  or  third  week. 

The  treatment  is  that  of  bronchopneumonia  under  other  circum- 
stances and  will  be  found  described  under  Pneumonia,  Chap.  IX,  and 
under  Measles,  Chap.  XIX,  and  Streptococcus  Pneumonia,  Chap.  X. 

It  is  necessary  to  emphasize  the  importance  of  the  open-air  treatment 
of  these  cases,  the  adoption  of  which  has  materially  lowered  the  mor- 
tality of  this  dread  complication. 

The  only  contraindication  is  a  laryngitis  of  severe  grade. 

Such  treatment  must  be  carried  out  with  rigid  regard  for  proper 


PERTUSSIS  535 

technique,  which  will  be  found  described  in  the  chapter  on  Pneumonia, 
Chap.  IX. 

Convulsions.  Next  to  bronchopneumonia  this  is  the  most  fatal 
of  the  complications  of  whooping  cough.  The  nervous  system  is  in 
such  an  irritable  condition  that  slight  sources  of  irritation  may  pre- 
cipitate a  convulsion  and,  indeed,  convulsions  may  occur  in  relatively 
mild  cases;  they  occur  in  all  degrees  of  severity,  from  trivial  short-lived 
spasms  to  prolonged  and  fatal  attacks. 

The  physician  is  rarely  at  hand  at  the  beginning  of  the  convulsion 
and  until  he  arrives  great  alarm  is  experienced  by  the  family  and  for 
their  sakes,  as  well  as  for  that  of  the  child,  some  instructions  should  be 
given  to  meet  the  condition.  Perhaps  the  best  measure  to  be  pursued 
by  the*  parent  is  the  giving  of  a  hot  mustard  bath  or  pack  and  because 
of  the  lesser  disturbance  and  handling  of  the  patient  demanded  by  the 
latter  procedure,  the  pack  is  to  be  preferred. 

Into  a  quart  of  luke-warm  water  a  tablespoonful  or  handful  of  mus- 
tard is  thrown,  a  towel  dipped  in  it  and  wrung  out  and  wrapped  about 
the  baby.  The  child  is  then  wrapped  about  with  a  blanket,  an  ice-cap 
put  at  the  head  or  lacking  the  ice-bag,  cracked  ice  in  a  towel,  a  hot  water 
bottle  at  the  feet,  a  small  fold  of  a  towel  tucked  in  the  corner  of  the 
mouth  to  protect  the  tongue  from  the  teeth,  but  with  care  not  to  ob- 
struct the  breathing  and  then  the  child  kept  as  .quiet  as  possible.  The 
pack  is  to  be  continued  for  ten  or  fifteen  minutes,  then  the  child  is 
wrapped  in  a  dry  blanket,  heat  kept  about  the  body  and  extremities 
and  cold  at  the  head. 

The  bath  is  prepared  by  using  mustard,  a  tablespoonful  to  the  gallon ; 
use  a  small  part  of  the  water  at  a  tepid  temperature  to  prepare  the 
mustard  and  then  add  the  rest  of  the  water,  raising  the  temperature 
of  the  bath  to  100°  F.  (It  is  to  be  remembered  that  hot  water  kills  the 
ferment  in  the  mustard  and  no  oil  will  be  generated  to  effect  an  irrita- 
tion.) The  bath  can  later  be  raised  three  or  four  degrees.  It  is  con- 
tinued some  ten  minutes  and  then  the  child  is  dabbed  dry,  wrapped 
in  a  blanket  and  treated  as  after  the  pack. 

The  physician's  first  effort  is  to  promptly  interrupt  the  convulsion 
and  his  next  to  prevent  its  recurrence. 

To  interrupt  the  convulsion  nothing  is  better  than  a  few  whiffs  of 
chloroform,  given  with  care,  not  crowded  down  upon  the  face.  As  soon 
as  the  desired  result  is  attained,  the  prevention  is  sought  in  the  adminis- 
tration of  chloral,  a  drug  toward  which  a  child  has  considerable  tolerance 
and  particularly  when  convulsed.  It  is  better  administered  by  the 
rectum  to  avoid  its  irritating  effects  on  the  stomach.  The  irritation 
to  the  rectum  is  prevented  by  the  use  of  an  ounce  or  two  of  warm  milk 


536  TREATMENT  OF  ACUTE  INFECTIOUS  DISEASES 

as  a  solvent.  The  dose  at  six  months  is  3  or  4  grains  (0.20-0.25  Gm.), 
at  one  year  5  or  6  grains  (0.30-0.35  Gm.),  and  by  some  given  in  doses 
of  gr.  x  (0.60  Gm.).  At  two  years  8  or  10  grains  (0.50-0.60  Gm.J.  The 
dosage  will  depend  somewhat  upon  the  severity  of  the  attack.  If  there 
is  twitching  at  the  end  of  an  hour  the  dose  may  be  repeated. 

The  drug  may  be  expected  to  take  effect  within  a  half  hour. 

Some  practitioners  add  bromide  to  the  chloral  in  doses  of  approxi- 
mately twice  as  much  bromide  as  chloral.  If,  however,  after  the  use 
of  the  chloroform  and  chloral  the  convulsions  recur,  morphine  should 
be  used. 

The  drug  should  be  used  hypodermically  and  in  sufficient  doses.  At 
six  months  the  dose  of  the  sulphate  usually  recommended  is  gr.  1/48 
(0.0015  Gm.),  at  one  year  gr.  1/24  (0.003  Gm.),  and  at  two  years  gr. 
1/16  (0.004  Gm.),  and  this  dose,  if  not  effectual  may  be  repeated  in  a 
half  hour  to  an  hour. 

Those  who  are  imbued  with  the  traditional  fear  of  morphine  in  infancy 
may  begin  the  initial  dose  with  a  slightly  smaller  amount,  but  satis- 
factory results  will  hardly  follow  in  severe  cases  unless  the  larger  doses 
are  used. 

In  obstinate  cases  I  would  recommend  a  lumbar  puncture.  I  have 
seen  very  satisfactory  results  in  a  few  cases  of  continued  convulsions, 
in  other  conditions  follow  this  procedure. 

Other  Measures  Recommended.  Holt  recommends  oxygen  in- 
halations as  of  value  in  some  cases  which  have  resisted  other  efforts. 

Still  recommends  urethane  to  prevent  recurrence  of  convulsions  in 
doses  of  gr.  1  3/4  (0.10  Gm.)  three  times  a  day  for  an  infant  of  nine 
months  and  in  doses  of  gr.  iii  to  gr.  viii  (0.2-0.50  Gm.)  three  times  a 
day  for  children  six  to  ten  years  old. 

Release  from  Quarantine.  There  is  a  great  disagreement  about 
the  length  of  time  a  case  may  be  a  source  of  danger,  ranging  from  six 
weeks  to  six  months.  It  seems  certain  that  the  most  contagious  period 
is  the  catarrhal  and  early  paroxysmal  and  a  whoop  may  continue  long 
beyond  the  infective  period.  As  the  infectious  stage  lasts  only  about 
three  weeks  as  a  rule,  six  weeks  would  seem  a  liberal  period  for  quaran- 
tine. 

Convalescence.  Another  reason  for  dread  of  this  disease  is  it 
prolonged  course.  The  average  duration  of  the  paroxysmal  stage  is 
six  weeks,  but  many  run  a  much  longer  period  and  especially  in  the 
winter,  when  pulmonary  complications  always  threaten.  The  par- 
oxysms often  last  for  months,  in  many  cases  long  after  the  infection 
has  surely  passed.  How  much  this  continued  cough  and  whoop  is 
due  to  a  curious  irritability  of  the  laryngeal  muscles  in  the  presence 


PERTUSSIS  537 

of  what  would  otherwise  be  a  trivial  catarrh  of  the  mucous  membranes 
of  the  laryngo-tracheal  tract  or  to  a  mere  habit  it  is  difficult  in  many 
instances  to  determine.  The  continued  administration  of  sedative  drugs 
to  subdue  this  occasional  cough  is  pernicious. 

In  the  young  children  and  infants  the  treatment  during  convales- 
cence resolves  itself  into  a  dietetic  one,  for  the  degree  of  malnutrition 
is  in  many  cases  grievous  and  the  powers  of  repair  much  reduced. 

Often  a  change  of  air  is  of  benefit  and  these  children  seem  to  do  par- 
ticularly well  at  the  shore,  in  a  warm  climate  and  even  a  sea  voyage 
may  be  of  great  benefit. 

Of  tonics,  iron  in  the  shape  of  the  bitter  wine  of  iron,  vinum  ferri 
amarum,  in  doses  of  3i  (4  c.c.)  in  water  three  times  a  day  or  Vallet's  mass 
or  Blaud's  pill  gr.  ii  to  gr.  v  (0.20-0.30  Gm.)  according  to  age  is  indicated 
and  in  infants  cod-liver  oil,  best  given  clear  in  doses  of  m.  xv  to  3i  (1-4 
c.c.)  three  times  a  day.  No  drugs  should  be  used  if  they  induce  gastric 
disorder  or  if  there  is  anorexia  and  a  coated  tongue.  The  bowels  should 
be  attended  to  by  the  use  of  the  milk  of  magnesia  in  doses  of  3  i  to  iv 
(4-15  c.c.)  or  cascara,  best  in  the  form  of  some  elixir  or  aromatic  prep- 
aration. 

Fresh  air  by  day,  the  sleeping  porch  by  night  are  of  vital  im- 
portance in  clearing  up  the  residuum  of  bronchial  catarrh  and  avoiding 
colds;  baths  with  cool  sponges  following  and  progressively  becoming 
colder,  exercise  in  the  open  to  the  point  of  comfortable  fatigue,  avoidance 
of  wet  feet  or  exposure  are  the  paths  to  health  and  these  measures  are 
the  more  important  in  view  of  the  fact  that  next  to  measles  no  disease  is 
so  commonly  followed  by  tuberculosis  as  pertussis. 

Removal  of  large  tonsils  and  adenoids  may  hasten  the  disappearance 
of  the  paroxysms  and  the  completion  of  convalescence. 

Prophylaxis.  It  is  agreed  that  vaccine  used  prophylactically  is  of 
real  value.  It  should  be  as  fresh  as  possible.  Three  subcutaneous  in- 
jections are  usually  given,  one  every  third  day.  Amount  used — Chil- 
dren, 500  million,  1000  million  and  2000  million;  adults  1000  million, 
2000  million  and  3000  million.  DEPARTMENT  OF  HEALTH,  THE  CITY 
OF  NEW  YORK. 

SUMMARY 

Distribution  of  the  family. 

Separate  the  suspects  from  other  children.     Remove  infants  from 

the  same  house,  if  possible. 
Contacts  should  be  hi  isolation  for  three  weeks. 
Contacts  may  receive  a  prophylactic  treatment  with  vaccine.    (See 

text.) 


538  TREATMENT  OF  ACUTE  INFECTIOUS  DISEASES 

Remember  modes  of  conveyance  by  spraying  of  coughing,  sneezing, 
laughing  and  talking,  for  this  can  occur  in  the  open  air;  hence, 
avoid  environment  of  a  case  even  in  the  open. 

During  an  epidemic  keep  children  from  gatherings  of  children,  par- 
ties, etc. 

Room. 

Light  and  air. 

Approach  to  verandah  or  balcony,  or  two  rooms,  for  change  from 

one  to  the  other,  permitting  of  thorough  ventilation. 
Occasional  formaldehyde  disinfection  of  room. 

Open  air. 

Milder  and  uncomplicated  cases  may  be  kept  up  and  out  of  doors  but 
must  avoid  contact  with  other  children. 

Change  of  climate  in  selected  cases. 

More  severe  and  complicated,  open  air,  if  patient  can  be  kept  cov- 
ered. 

Avoid  draughts,  high  winds  and  dust.  If  feasible,  temperature  of 
room  should  be  from  65°  F.  to  70°  F. 

Two  children  should  not  be  treated  in  the  same  room. 

Clothing. 
Flannel  next  the  skin.    Avoid  over-loading. 

Nurse. 

Should  not  be  urged  to  take  the  case  unless  she  has  had  pertussis. 

Avoid  contact  with  other  children. 

Should  never  leave  her  patient  when  on  duty  if  a  young  child  or 

infant,  lest  it  suffocate  in  a  paroxysm  or  have  a  convulsion. 
Prophylactic  vaccination. 

Physician. 

Should  wear  gown. 

Should  wash  face  and  hands  on  leaving  case. 
Should  not  go  at  once  to  another  child. 

If  he  has  not  had  pertussis  he  may  wear  a  small  mask,  like  a  chloro- 
form mask,  wet  with  1-20  phenol. 

Should  avoid  standing  in  front  of  a  patient  during  a  paroxysm. 
Prophylactic  vaccination. 

Precautions. 

Strict  isolation  to  quarters  assigned,  if  in  the  house. 
Avoidance  of  other  children  if  allowed  out  of  doors. 
Secretions  should  be  received  on  gauze  and  burned. 
Bed-linen,  night  clothes,  handkerchiefs,  towels,  etc.,  boil  an  hour  or 

soak  overnight  in  1-20  phenol,  then  launder. 
Domestic  pets  may  carry  the  disease  and  should  be  excluded. 


PERTUSSIS  639 

Bed. 

For  preparation  of  bed  for  open  air,  see  Pneumonia,  Chap.  IX. 
Indications  for  remaining  in  bed. 

When  there  is  fever. 

When  there  are  complications. 

When  there  is  great  nervous  irritability. 

Bath. 

Cleansing  bath  of  soap  and  warm  water  daily,  on  a  blanket  or  be- 
tween blankets. 

Diet. 

Older  patients  and  mild  uncomplicated  cases,  no  change. 
When  vomiting  is  present  and  gastro-intestinal  symptoms  are  pres- 
ent. 

Feed  right  after  a  paroxysm  as  there  is  then  a  period  of  quiescence 
and  avoid  feeding  near  an  anticipated  paroxysm,  as  it  precipi- 
tates it. 

When  paroxysms  occur  hourly  or  oftener. 
Give  small  quantities  of  high  calorie  food  frequently. 
Milk  plain  or  modified. 
Dilute  with  water  half  and  half . 
Use  lime  water  1-20  of  milk. 

Dilute  half  and  half  with  barley  or  arrowroot  water. 
Milk  gruels  of  barley,  wheat  flour,  rice,  arrowroot,  malted  or 

farinaceous  infant  foods. 

Whey,  buttermilk,  koumys,  animal  broths  thickened  with  cereals 
and  farinaceous  foods,  custards,  baked  or  soft,  jellies  with  sugar, 
junket,  soft  egg,  albumin  water,  wet  toast,  milk  toast,  softened 
rusks,  boiled  rice  and  cereal. 

Avoid  dry  foods,  they  irritate  and  provoke  paroxysms. 
Dilute  infants'  milk  mixtures. 
Rectal  feeding. 

Only  hi  most  severe  cases.  Cannot  be  utilized  for  any  considerable 
period. 

Hygiene. 

Daily  baths. 
Ordinary  oral  hygiene. 

Sprays  for  nose  of  2  per  cent,  to  4  per  cent,  boric  acid  solution  or 
quarter  to  half  strength  DobelTs  solution. 

Bowels. 

Use  cascara  in  older  children  and  milk  of  magnesia  in  the  younger 
or  other  simple  and  mild  cathartics. 

Fever. 

In  uncomplicated  cases  needs  no  treatment. 
Dictates  remaining  in  bed. 


540  TREATMENT  OF  ACUTE  INFECTIOUS  DISEASES 

Cough. 
May  cause  suffocation,  convulsions,  cerebral  hemorrhage,  exhaustion, 

frequent  vomiting  and  malnutrition. 
Avoid  excitement  or  emotional  state. 
Avoid  dust,  chilling,  cold  beds,  draughts;  quiet  child's  alarm  by 

assurance.    Fresh  air. 
Mild  cases  require  no  treatment.    Drugs  only  upset. 

More  severe  cases. 

Local  procedures. 

Mechanical  support,  including  Kilmer  belt.    (See  text.) 
Sprays  and  local  applications  to  the  nose  of  doubtful  value. 
Inhalations. 
Medicated  steam. 

Compound  tincture  of  benzoin  or  creosote,  5i  or  ii  (4-8  c.c.) 
on  hot  water,  or  a  combination  of  creosote  5ii  (8  c.c.)  and  com- 
pound tincture  of  benzoin  5ii  (60  c.c.). 
May  use  pitcher,  a  carafe,  simple  kettle,  with  paper  cones  or 

regular  croup  kettle. 

Best  under  tent.    (For  technique,  see  text.) 
May  use  in  place  of  benzoin,  creosote  or  oil  of  eucalyptus  in  same 

manner. 
Chloroform. 

When  severe  and  threatening  convulsions  or  asphyxia. 
Few  drops  on  handkerchief,  sponge  or  towel. 
Other  measures  to  interrupt  prolonged  and  dangerous  spasm. 
Pull  jaw  down  and  forward  as  hi  giving  an  anesthetic  (Nagele). 
Plunging  hands  in  cold  water  (Smith  quoted  by  Ker). 
Most  severe  form  of  spasm. 
Intubation.    (See  Diphtheria,  Chap.  XVIII.) 

Drugs. 

Antipyrin. 

At  6  months  gr.  i  (0.06  Gm.)  every  three  or  every  two  hours. 

At  1  year  gr.  iss.  (0.1  Gm.). 

At  2  years  gr.  ii  (0.15  Gm.)  every  six  to  four  hours  (Holt). 
Towards  night  combine  with  bromide  of  soda. 

At  6  months  gr.  ii  (0.15  Gm.). 

At  1  year  gr.  iii  (0.20  Gm.). 

At  2  years  gr.  iv  (0.30  Gm.). 

Don't  use  it  in  weakly  children  and  in  pneumonia. 

Idiosyncrasies  for  antipyrin.    (See  text.) 
Belladonna. 

Has  to  be  used  to  the  physiological  limit. 

One  should  begin  with  a  small  dose  as  idiosyncrasies  are  not 

uncommon. 
Jacobi's  dose. 

Six  drops  of  the  tincture  of  belladonna  three  times  a  day.    This 
should  cause  a  feverish  flush  on  the  cheeks  hi  hah*  an  hour 


PERTUSSIS  541 

and  last  half  an  hour;  if  it  does  not  the  dose  must  be  increased 

up  to  7,  8,  9,  or  more  drops. 
One  must  get  the  flush  each  time. 

It  is  better  to  begin  with  smaller  doses  than  the  above,  e.  g., 
At  6  months  begin  with  in.  ss.-i  (0.030-0.060  c.c.). 
At  1  year,  m.  i-ii  (0.060-0.150  c.c.). 
At  2  years,  m.  iii  (0.20  c.c.). 

Increase  a  minim  a  dose  a  day  up  to  the  point  of  inducing  flush- 
ing. 

For  other  signs  of  full  dose  and  for  idiosyncrasies,  see  text. 
Bromides. 

Best  combined  with  antipyrin  as  above. 
Opium  and  its  derivatives. 

Use  only  when  exhaustion  threatens  and  other  measures  fail. 
Best  used  at  night. 
Codeine  best. 
Use  phosphate  or  sulphate. 

At  6  months,  gr.  1/100  (0.0006  Gm.). 

At  1  year,  gr.  1/60  (0.001    Gm.). 

At  2  years,  gr.  1/40  (0.0015  Gm.). 

Older  children,  gr.  1/8  to  gr.  1/4  (0.01-0.015  Gm.). 

Paregoric  (Tr.  opii  camphorata). 

At  6  months  m.  iii-iv         (0 . 20-0 . 30  c.c.) . 

At  1  year  m.  v-x  (0 . 30-0 . 60  c.c.) . 

At  2  years  m.  x-xv  (0.60-1        c.c.). 

At  3  years  3 ss.  (2  c.c.). 

Dover's  powders  Pulv.  ipecac  et  opii.). 

At  6  months  gr.  1/8  (0.008  Gm.). 

At  1  year  gr.  ss.  (0.030  Gm.). 

At  2  years  gr.  i  (0.060  Gm.). 

At  5  years  gr.  ii  (0. 15    Gm.). 

Measures  recommended  by  other  authority. 

Quinine.    (See  text.) 
Heroine.    (See  text.) 
Bromoform.    (See  text.) 
Fluroform.    (See  text.) 
Antitussin.    (See  text.) 

Benzyl  benzoate,  20  drops  of  20  per  cent,  solution  given  in  milk 
every  3  hours  (dose  for  two  years  of  age). 

Specific  treatment. 
Vaccines.    (See  text.) 

Insomnia. 

Relieved  by  measures  relieving  paroxysms,  especially  bromides  and 

antipyrin. 
Chloral  at  night. 

At  6  months  gr.  ii  (0.15  Gm.). 

At  1  year  gr.  iii  to  iv  (0.20-0.30  Gm.). 


542  TREATMENT  OF  ACUTE  INFECTIOUS  DISEASES 

May  be  repeated  in  two  hours. 
Give  by  rectum  in  2  ounces  of  warm  milk. 
Trional. 

At  2  years  gr.  ii  to  gr.  iv  (0.15-0.30  Gm.). 
With  threatened  exhaustion  give  opium  in  doses  as  given  above. 

Complications. 

Vomiting  of  severe  type. 

Diet.    (See  above  in  summary.) 
Belt.    (See  above  in  summary.) 
When  accompanying  cough. 
Measures  used  to  control  cough. 
(See  above  in  summary.) 
Unaccompanied  by  cough. 

Measures  to  relieve  gastric  irritation. 

Sodium  bicarbonate  gr.  v  (0.30  Gm.)  with  the  food. 
Cocaine  hydrochloride,  gr.  1/6  (0.010  Gm.)  twice  a  day  (Eustace 
Smith  by  Ker). 

Diarrhea. 

Regulation  of  diet. 

Calomel  occasionally,  gr.  1/10  (0.006  Gm.)  every  ten  minutes  for  ten 

doses,  or  gr.  1/4  (0.015  Gm.)  every  quarter  hour  for  four  doses, 

followed  by 
Bismuth  subnitrate,  gr.  xx  to  gr.  xxx  (1.30-2  Gm.)  every  three  or 

four  hours. 
Occasional  irrigations. 

Ulcer  of  the  frenum. 

Use  boric  acid  (2  per  cent,  to  4  per  cent,  solution)  as  a  mouth  wash. 
Silver  nitrate,  touch  occasionally  with  the  stick. 
Dental  assistance  to  protect  tongue. 

If  severe  may  extract  the  incisors  responsible,  if  they  are  of  the 
first  set. 

Nose  bleed  (epistaxis). 

Spray  with  adrenalin  (1-10,000)  or  apply  adrenalin  (1-1,000)  on 

cotton  to  bleeding  point.    If  severe,  plug  nares. 
Tannic  acid  mixed  to  the  consistency  of  a  syrup  applied  on  gauze 

(Coakley). 

Bronchopneumonia. 

(See  Pneumonia,  Chap.  IX.) 
Open  air. 

(For  contraindications,  see  Pneumonia,  Chap.  IX);  also  severe 
laryngitis. 

Convulsions. 

Parent  or  nurse  may  initiate  treatment  with  hot  mustard  bath  or 

pack. 
(For  technique,  see  text.) 


PERTUSSIS  543 

To  interrupt  convulsion, 

Chloroform,  give  a  few  whiffs. 
When  the  convulsion  is  interrupted, 
Prevent  recurrence. 
Chloral. 

At  6  months  gr.  iii  to  gr.  iv  (0.20-0.30  Gm.). 
At  1  year  gr.  v  to  gr.  vi  or  even  gr.  x  (0.30-0.40-0.60  Gm.). 
At  2  years  gr.  viii  to  gr.  x  (0.50-0.60  Gm.). 
Give  by  the  rectum  in  1  or  2  ounces  (30-60  c.c.)  of  warm 
milk.     If  there  is  twitching  at  the  end  of  an  hour  repeat 
the  dose. 

Bromides  may  be  added  to  the  chloral  in  doses  of  gr.  ii  (0.15 
Gm.)  of  the  bromides  to  gr.  i  (0.060  Gm.)  of  the  chloral. 
If  the  convulsions  recur  in  spite  of  this,  use 
Morphine  sulphate 

At  6  months  gr.  1/48  (0.00125  Gm.). 
At  1  year  gr.  1/24  (0.0025  Gm.). 
At  2  years  gr.  1/16  (0.004  Gm.). 

Give  hypodermically. 
If  convulsions  or  twitching  persist,  repeat  dose  in  one-half 

to  one  hour. 
In  obstinate  cases. 
Try  lumbar  puncture. 

(For  technique,  see  Cerebro-spinal  Meningitis,  Chap.  XXV.) 
Other  measures  recommended. 
Oxygen  inhalations  (Holt). 
Urethane  (Still).    (See  text.) 

Release  from  quarantine. 

When  paroxysms  cease  unless  unduly  prolonged.    (See  text.) 
Usually  about  six  weeks. 

Convalescence. 

Diet,  especially,  in  malnutrition  of  infants  and  young  children  im- 
portant. 

Change  of  climate. 

Especially  to  sea-shore. 
Warm  climate. 

Tonics. 
Iron. 
Bitter  wine  of  iron  (Vinum  ferri  amarum)  3i-ii  (4r-8  c.c.)  three 

times  a  day. 
Vallet's  mass  (Massa  ferri  carbonatis)  gr.  i-iii  (0.060-0.20  Gm.) 

three  times  a  day,  or 

Blaud's  pill  (Pil.  ferri  carb.)  same  dose,  gr.  iii  (0.20  Gm.). 
Cod  liver  oil  m.  xv-3i  (1-4  c.c.)  three  times  a  day. 

Keep  bowels  in  order. 


544  TREATMENT  OF  ACUTE  INFECTIOUS  DISEASES 

Hygiene. 

Fresh  air  by  day. 
Sleeping  porch  at  night. 
Exercise  hi  the  open  air. 
Avoidance  of  wet  feet. 
Watch  constantly  for  any  signs  of  tuberculosis. 

Prophylaxis. 

Vaccines. 
Fresh  as  possible. 
Dosage.    (See  text.) 
Intervals.    (See  text.) 


CHAPTER  XXIII 

MUMPS 

(PAROTITIS) 

THIS  disease  of  uncertain  etiology  affects  characteristically,  but 
not  exclusively,  the  parotid  glands.  It  is  rare  in  infancy,  finds  its  maxi- 
mum incidence  in  the  second  and  third  lustra,  affects  many  young 
adults,  but  is  again  rare  in  later  life. 

It  is  very  rarely  fatal,  but  entails  much  discomfort  and  in  its  compli- 
cations sometimes  serious  results. 

There  is  good  reason  to  believe  that  the  organism  isolated  and  de- 
scribed by  Laveran  and  Catrin,  a  diplococcus,  is  the  causative  agent 
of  the  disease. 

Symptoms.  Usually  the  enlarging  gland  is  the  first  symptom.  A 
few,  however,  will  have  signs  of  a  general  infection  with  pains  variously 
distributed  over  the  body.  The  jaws  feel  stiff  and  there  may  be  a  tem- 
porary loss  of  taste.  Sour  food  may  provoke  a  pain  in  the  jaw,  but  this 
is  not  constant.  It  has  often  been  thought  an  early  and  significant  symp- 
tom. The  parotid  swells,  giving  rise  to  a  characteristic  appearance 
of  the  face.  Sometimes  the  sublingual  or  submaxillary  glands  may  share 
in  the  affection  or  may  be  exclusively  attacked.  With  the  parotitis  there 
may  be  a  sense  of  fullness  in  the  ears  and  some  degree  of  deafness.  The 
white  blood  count  ranges  from  5000-8000  and  there  is  an  actual  and 
relative  increase  of  lymphocytes. 

Distribution  of  the  Family.  I  am  a  firm  believer  in  the  pre- 
vention in  every  individual  of  any  kind  of  infection  where  possible; 
so,  while  many  look  upon  mumps  as  of  slight  importance,  if  not  as  an 
amusing  incident,  such  serious  consequences  can,  to  be  sure  rarely, 
ensue  that  I  advise  isolation  of  the  patient  or  removal  of  the  other  chil- 
dren and  young  adults  to  other  premises. 

The  period  of  incubation  is  from  twelve  to  twenty-six  days;  hence, 
these  contacts  should  not  expose  susceptible  individuals  until  the  ex- 
piration of  twenty-six  days. 

I  am  aware  that  only  rarely  will  such  a  recommendation  be  followed 
by  the  wage  earner  and  that  much  protest  will  be  voiced  in  cases  of  the 
school  children,  but,  at  least,  in  the  case  of  the  latter,  they  should  not  be 
allowed  to  go  to  school  longer  than  ten  days  after  exposure,  which  period 


546  TREATMENT  OF  ACUTE  INFECTIOUS  DISEASES 

trespasses  close,, on  the  appearance  of  prodromal  symptoms  if  they  are 
infected  and  during  this  period  of  invasion  they  are  highly  contagious. 

These  contacts  should  not  return  to  the  environment  of  the  patient 
until  the  quarantine  has  been  raised. 

Room.  A  well  lighted  and  well  ventilated  room  as  free  from  fur- 
nishings as  possible  should  be  chosen  and  a  bed,  preferably  of  the 
hospital  type. 

A  patient  who  has  any  fever  or  other  evidence  of  constitutional  reac- 
tion to  his  infection  should  be  confined  to  bed.  Mild  cases  in  children 
in  whom  neither  the  one  nor  the  other  obtains  may  be  allowed  up,  but 
confined  to  the  room.  To  male  adults,  the  high  incidence  (about  30  per 
cent.)  of  orchitis  as  a  complication,  its  distressing  symptoms  and  the 
possibility  of  atrophy  should  be  explained  with  the  statement  that 
remaining  in  bed  until  the  parotid  swelling  has  subsided  plus  a  margin 
of  safety,  in  all  some  ten  days,  is  believed  to  lessen  very  materially  the 
probability  of  this  complication. 

The  infection  comes  from  the  buccal  and  nasal  secretions  and  "these 
should  be  destroyed. 

Infection  through  the  third  person  is  very  rare,  because  the  infecting 
organism  is  very  short  lived,  but  the  physician  should  wash  his  hands 
thoroughly  on  leaving  the  patient  and  avoid  an  immediate  call  on 
another  susceptible  individual.  The  nurse  should  take  similar  precau- 
tions in  her  absence  from  the  sick-room. 

Baths.  A  cleansing  bath  with  soap  and  water  should  be  given 
every  day. 

Diet.  The  difficulty  of  eating  makes  a  fluid  diet  or  a  semi-solid 
diet  a  necessity.  Milk  and  milk  preparations,  cereals,  milk  broths, 
meat  soups,  plain  or  thickened  with  farinaceous  foods,  or  with  cracker 
soaked  in  them,  custard,  soft  eggs,  soft  toast  and  similar  substances 
may  be  used,  but  the  quantity  should  be  such  as  to  satisfy  the  patient's 
appetite.  If  there  be  no  fever  and  the  patient's  condition  will  permit 
the  use  of  his  jaws,  a  more  solid  food,  meat,  fish  and  vegetables  may  be 
used. 

Water  or  drinks  made  of  fruit  juices  may  be  allowed  and  in  febrile 
cases  urged. 

Acid  food  or  drinks  often  cause  a  sharp  pain  in  the  jaws  and  has  been 
looked  on  by  many  as  characteristic,  but  this  does  not  always  occur  and 
the  giving  or  withholding  of  such  articles  depends  purely  on  the  absence 
or  presence  of  pain  when  taking  them. 

Care  of  the  Patient.  Since  the  infectious  material  is  resident 
in  the  secretions  of  the  nose  and  mouth  and  since  a  mixed  infection 
of  the  parotid  gland  leading  on  to  suppuration  may  occur  and  presum- 


MUMPS  547 

ably  by  way  of  Steno's  duct,  the  hygiene  of  the  mouth  becomes  of 
importance. 

One  may  use  boric  acid  solution  2  per  cent,  to  4  per  cent,  as  a  mouth 
wash  or  a  DobelPs  solution,  diluted  1/2  to  3/4.  These  same  solutions 
may  be  used  in  the  nose  in  a  spray  or  applied  with  a  swab  on  an  appli- 
cator or  wooden  tooth-pick. 

Bowels.  At  the  beginning  of  the  treatment  the  bowels  should 
be  effectually  moved  by  calomel  or  a  salt,  or  both,  as  gr.  1/4  (0.015  Gm.) 
calomel  every  fifteen  minutes  until  gr.  iss.  (0.10  Gm.)  are  taken,  followed 
in  two  hours  by  gss.  (15  Gm.)  of  Epsom,  Rochelle  or  Glauber's  salt. 

During  the  illness  the  bowels  may  be  moved  by  a  mild  saline,  like  a 
Seidlitz  powder,  citrate  of  magnesia  or  Hunyadi  water  or  its  equivalent 
in  one  of  the  many  aperients  on  the  market. 

Fever.  Only  rarely  is  the  fever  of  any  moment.  Its  discomforts  are 
to  be  met  by  cool  sponging.  In  the  early  stages,  if  accompanied  by 
pains  or  aches  acetanilid,  gr.  iss.  (0.10  Gm.)  or  phenacetin  gr.  iii  (0.20 
Gm.)  can  be  given  at  hourly  or  two  hour  intervals. 

Treatment  of  the  Parotitis.  In  the  majority  of  cases  no  treat- 
ment is  required  and  no  discomfort  is  experienced  beyond  a  stiffness 
in  the  muscles  of  the  jaw.  It  is  altogether  better  not  to  interfere  at  all 
in  such  cases,  as  is  often  done  merely  because  there  is  a  swelling  and 
either  the  doctor  or  the  patient  feels  that  something  ought  to  be  done. 

The  swelling  lasts  a  week  to  ten  days,  but  the  second  parotid  may 
be  affected  so  late  as  to  drag  the  period  out. 

When  there  is  pain  and  marked  discomfort  in  the  glands  efforts  at 
relief  may  be  made  first  by  topical  application,  of  heat,  cold  or  drugs. 

LOCAL  TREATMENT 

Heat.  In  milder  cases  heat  is  afforded  by  the  patient  himself  by 
the  application  of  a  dry  dressing,  as  of  absorbent  cotton  or  of  non- 
absorbent  cotton,  covering  the  affected  part  liberally  and  held  in  place 
by  a  bandage. 

Dry  heat  can  also  be  applied  by  the  use  of  the  hot  water  bottle 
or  a  bag,  the  size  of  which  is  adapted  to  the  swelling,  filled  with  fine 
scouring  sand  or  salt  and  heated  in  the  oven. 

Hot  fomentations  are  often  efficacious.  Two  or  three  layers  of 
thick  flannel  are  laid  in  a  towel  and  boiling  water  poured  upon  them. 
The  water  is  wrung  out  of  them  by  twisting  them  in  the  towel  by  turning 
the  ends  of  the  towel  in  opposite  directions. 

The  degree  of  heat  should  first  be  tested,  a  flirt  in  the  air  made  to 
throw  off  an  excess  of  steam  or  hot  vapor,  the  edges  turned  under  to 


548  TREATMENT  OF  ACUTE  INFECTIOUS  DISEASES 

prevent  any  drip  of  hot  water  and  a  dry  flannel  placed  over  them. 
They  should  be  replaced  every  few  minutes  before  they  get  cool  and 
this  kept  up  for  fifteen  to  twenty  minutes  at  a  time.  When  taken  off 
the  glands  should  be  covered  with  dry  cotton.  This  may  be  repeated 
as  often  as  it  affords  comfort. 

Cold.  Some  patients  find  more  relief  from  cold  than  from  heat. 
Cold  may  be  applied  in  an  ice-bag.  The  circular  ice-bag  is  the  best. 
The  pieces  of  ice  should  be  about  the  size  of  the  end  of  one's  fingers, 
only  enough  water  put  in  to  cover  the  ice  and  then  the  air  pressed  out 
and  the  cover  screwed  on. 

This  makes  the  bag  apply  itself  closely  to  the  part,  which  it  will  not 
do  if  it  contains  air.  Under  the  bag  should  be  a  layer  of  flannel,  be- 
tween it  and  the  face.  Instead  of  the  ice-bag  an  ice  poultice  may  be  used. 

Ice  Poultice.  "Cut  two  pieces  of  oiled  muslin  the  required 
shape  and  size,  place  them  together  and  turn  over  the  edges  about 
an  eighth  of  an  inch  all  round.  Bind  with  adhesive  plaster,  leaving 
unbound  a  small  section  at  the  top  till  the  ice  has  been  put  in.  Fasten 
the  corners  securely,  strengthening  them  with  extra  pieces  of  adhesive 
plaster.  Mix  the  ice  after  breaking  it  into  pieces  the  size  of  a  walnut, 
with  one-third  as  much  flaxseed  or  bran,  which  will  absorb  the  water 
as  the  ice  melts,  and  with  a  small  amount  of  salt,  which  will  intensify 
the  cold. 

"  Cover  the  poultice  with  gauze  before  applying,  and  hold  it  in  place 
either  with  a  binder  or  a  four-tailed  bandage,  as  the  position  requires." 
Quoted  from  Practical  Nursing  by  Maxwell  and  Pope.  Salt  should  be 
used  cautiously. 

Drugs.  It  is  questionable  whether  any  of  the  ointments  and 
Uniments  applied  do  actual  good.  Among  those  which  have  been  rec- 
ommended, I  will  mention  camphorated  oil  (linimentum  camphorse), 
Belladonna  ointment  of  the  pharmacopeia,  Guiacol,  1  in  20  of  vaseline 
and  lanolin  equal  parts,  and  ichthyol  ointment  10  per  cent,  to  25  per 
cent. 

Now  and  then  a  gland  goes  on  to  suppuration.  In  this  case  it  should 
be  incised. 

While  the  seat  of  the  infection  is  peculiarly  the  parotid  glands,  other 
glands  may  at  times  be  affected,  such  as  the  submaxillary,  the  sub- 
lingual,  the  testicle,  the  ovary,  the  mammary  glands,  the  pancreas 
and  still  more  rarely  the  lachrymal  and  thyroid  glands.  Of  course, 
the  appreciation  of  their  involvement  by  this  specific  infection  comes 
only  when  the  parotid  swelling  tells  the  tale  or  in  the  presence  of  an 
epidemic,  when,  even  in  the  absence  of  a  parotid  swelling  the  signifi- 
cance of  the  glandular  swellings  is  understood. 


MUMPS  549 

The  treatment  of  the  submaxillary  and  sublingual  glands  is  the  same 
as  that  of  the  parotid.  When  the  testicle  is  involved  one  may  speak  of 

Complications.  Orchitis.  It  may  be  prefaced  that  testicular 
pains  during  mumps  are  not  uncommon  even  when  the  organ  is  not 
apparently  involved.  This  complication  is  very  rare  in  boys  before 
puberty,  but  after  that  period  its  frequency  is  given  by  some  authorities 
as  high  as  33  per  cent.  With  the  involvement  of  the  testis  there  is 
usually  an  exacerbation  or  recrudescence  of  the  constitutional  symptoms. 
While  in  some  cases  the  discomfort  is  trivial,  in  many  the  pain  is  severe. 
This  may  be  the  earliest  and  only  organ  involved.  The  diagnosis  in 
this  case  would  depend  on  the  presence  of  an  epidemic  or  exposure. 

Ker  calls  attention  to  the  fact  that  accompanying  the  orchitis  there 
may  be  a  slight  urethral  discharge.  Even  in  the  presence  of  the  paro- 
titis this  discharge  may  be  misunderstood  as  gonorrheal  or  on  the  other 
hand  an  actual  gonorrheal  discharge  might  be  assumed  to  be  a  part 
of  the  orchitic  involvement.  A  smear  for  the  detection  of  the  gono- 
coccus  of  Neisser  should  be  taken. 

Remaining  in  bed  during  even  a  trivial  attack  of  mumps  lessens  the 
likelihood  of  an  orchitis  very  materially.  If  the  patient  is  up  and  about, 
he  must,  of  course,  be  made  to  go  to  bed. 

A  proper  suspensory,  to  support  the  drag  of  the  inflamed  organ 
must  be  applied  as  the  first  and  most  essential  measure  and,  indeed, 
in  the  milder  cases  little  else  is  required. 

A  ready  contrivance  for  affording  support  is  a  pillow  stuffed  between 
the  thighs  well  up  against  the  perineum;  or  the  thighs  may  be  brought 
together  and  a  sheet  of  adhesive  plaster  3  or  4  inches  wide  spread  across 
the  thighs  on  which  the  scrotum  may  rest.  The  disadvantage  of  these 
methods  is  that  they  interfere  with  a  freedom  of  motion  in  the  bed.  A 
"T"  bandage,  one  arm  going  about  the  waist  and  the  other  between 
the  thighs,  to  support  the  scrotum,  split  just  beyond  the  point  of  support, 
each  half  to  be  attached  above  to  the  part  around  the  waist  on  either 
side  or,  if  accessible,  one  of  the  many  forms  of  support  on  the  market. 

A  dry  poultice  may  be  used,  which  consists  of  an  abundance  of 
cotton  about  the  scrotum,  which  retains  the  heat  of  the  body. 

A  time-honored  application  is:  Lotio  Plumbi  et  Opii;  Lead  acetate, 
128  grains  (8.5  Gm.) ;  Tincture  of  opium,  4  drams  (15  c.  c.) ;  and  water 
to  make  1  pint  (475  c.c.).  (Shake  before  using.) 

The  bowels  must  be  kept  freely  open  with  salines  during  the  run  of 
orchitis. 

The  condition  is  likely  to  last  from  three  to  seven  da}rs  and  resolve 
without  further  trouble.  The  danger  lies  in  the  fact  that  in  rare  cases 
atrophy  of  the  testis  occurs.  In  the  females  either  the  ovaries  or  the 


550  TREATMENT  OF  ACUTE  INFECTIOUS  DISEASES 

mammary  glands  may  be  affected.  There  is  tenderness  over  the  site 
of  the  ovaries  but  the  organs  are  rarely  enlarged.  Hot  applications 
over  the  abdomen  or  over  the  mammary  glands,  using  the  measures 
advised  for  the  parotid  glands,  may  be  used. 

Vulvitis,  too,  is  an  unusual  manifestation  in  the  female.  It  is 
to  be  treated  by  local  applications  of  boric  acid  solution,  Sitz  baths 
and  hot  compresses.  Dr.  Joseph  Sailer  reports  14  cases  in  4000  or  3.5  per 
cent.  He  found  it  to  occur  most  commonly  on  the  5th  to  8th  day,  but  it 
sometimes  comes  on  late  in  convalescence. 

Pancreatitis.  The  vomiting,  sometimes  severe,  the  pain  and  ten- 
derness in  the  epigastrium  and  left  hypochondrium,  might  be  readily 
attributed  to  a  gastric  disturbance,  if  one  did  not  have  in  mind  the  pos- 
sible involvement  of  the  pancreas.  Jaundice  may  occur.  My  friend, 
Dr.  Geo.  Blumer,  tells  me  he  has  seen  a  case  go  to  operation,  disclosing 
an  extensive  fat  necrosis. 

The  treatment  consists  in  the  application  of  heat  or  cold  over  the 
site  of  pain  and  tenderness  and  a  limitation  of  diet  and  especially  on 
fat,  both  to  afford  the  gland  a  relief  from  excitation  of  food  taken 
and  the  dyspeptic  disturbances  that  might  ensue  from  insufficiency 
of  the  pancreatic  ferments.  The  trouble  is  short-lived  and  the  dimi- 
nution in  food  will  have  no  significance. 

Thymus  gland.  Dr.  Sailer  reports  the  rare  involvement  of  this 
gland,  0.1  per  cent,  of  his  cases. 

There  was  localized  edema  over  the  manubrium,  pitting  on  pressure. 
This  may  extend  from  the  cricoid  cartilage  to  the  middle  of  the  gladiolus 
and  on  either  side  of  the  mid-clavicular  line,  with  a  circular  or  oval 
outline.  There  is  no  tenderness  to  pressure  nor  nausea.  The  X-ray 
detects  the  enlarged  outline  of  the  gland. 

Meningo-encephalitis.  The  large  number  of  cases  of  mumps 
occurring  in  our  camps  during  the  late  war  bore  in  upon  us  the  fre- 
quency and  importance  of  this  complication.  Probably  it  is  with  rare 
exception,  the  sole  cause  of  death.  Haden  reported  9  cases  in  a  series  of 
476  of  mumps,  nearly  2  per  cent.  There  is  headache,  nausea  and  vomit- 
ing which  may  be  severe,  slight  rigidity  of  the  neck,  perhaps  Kernig's 
signs,  but  not  well  marked,  drowsiness  and  high  fever.  The  spinal 
cord  fluid  is  clear,  under  an  increase  of  pressure,  shows  a  pleocytosis, 
lymphocytosis  usually  predominating,  and  Fehling  reducing  bodies 
in  60  per  cent,  of  the  cases. 

It  may  be  the  earliest  manifestation  of  the  infection  and  simulate 
very  closely  a  tubercular  meningitis.  In  one  such  case  I  made  the 
diagnosis  on  the  basis  of  its  occurring  during  an  epidemic  of  mumps 
and  confirmed  by  a  tender  testicle,  developing  later  an  orchitis. 


MUMPS  551 

It  is  assumed  that  one  is  dealing  with  a  meningoencephalitis.  I 
am  not  conversant  with  pathological  reports  on  such  cases.  One  wonders 
if  the  pituitary  or  pineal  glands  might  not  be  involved  to  account  for 
the  symptom  complex. 

Lumbar  Puncture  is  a  valuable  therapeutic  measure,  as  it  af- 
fords much  relief  to  the  headache. 

An  ice-bag  applied  to  the  head  may  be  efficacious  to  relieve  headache. 
In  severe  cases  morphine  may  be  indicated  in  doses  depending  on  age. 
(See  Cerebro-spinal  Meningitis,  Chap.  XXV.) 

Nephritis,  arthritis,  have  both  been  mentioned  in  the  literature 
as  having  complicated  this  disease,  but  they  are  of  extreme  rarity  and 
are  to  be  treated,  when  they  occur  as  under  other  circumstances. 

No  other  treatment  of  the  condition  is  needed,  except  bromides  for 
nervousness,  trional  for  sleeplessness,  small  doses  of  phenacetin  for  pain 
and  in  the  very  severe  cases  small  doses  of  morphine. 

Release  from  Quarantine.  Isolation  should  continue  about  ten 
days  after  the  swelling  has  ceased,  but  in  prolonged  cases  it  may  be  cut 
down  to  a  week  after  the  disappearance  of  the  local  trouble. 

Convalescence.  Is  usually  rapid  and  needs  little  else  than  fresh 
air  and  good  food.  If  a  tonic  is  desirable,  one  may  use  iron,  the  bitter 
wine  in  children  in  doses  of  3i  (4  c.c.)  three  times  a  day  and  the  B  laud's 
pill  in  the  older  cases  in  doses  of  gr.  iii  (0.20  Gm.)  to  gr.  v  (0.30  Gm.) 
three  times  a  day. 

Disinfection.  The  infective  material  is  easily  destroyed  on  ex- 
posure to  light  and  air  and  many  men  think  it  unnecessary  to  do  more 
than  clean  and  ventilate  the  sick-room. 

If,  however,  one  wishes  to  take  extreme  precautions  it  may  be  disin- 
fected and  the  clothes  treated  as  described  under  Scarlet  Fever.  (See 
Chap.  XVII.) 

SUMMARY 

Distribution  of  the  family. 

Contacts  should  not  expose  susceptible  individuals  until  incubation 
period  of  three  to  four  weeks  has  passed. 

Patient 

Should  be  confined  to  room. 
If  there  is  fever  or  complications,  to  the  bed. 
Remaining  in  bed  lessens  the  incidence  of  orchitis. 

Room. 

Good  light  and  ventilation. 


552  TREATMENT  OF  ACUTE  INFECTIOUS  DISEASES 

Physician. 

Should  wash  his  hands  carefully  on  leaving  patient  and  not  go  directly 
to  a  susceptible  person. 

Nurse. 
Should  take  similar  precautions. 

Baths. 

Daily  cleansing  bath  of  soap  and  water. 

Diet. 

Fluid  or  semi-solid  on  account  of  difficulty  of  eating. 

(For  suitable  articles,  see  text.) 

Acid  foods  or  drinks  often  cause  sharp  pain  in  jaws. 

Care  of  mouth. 

Remember  the  danger  of  mixed  infection  of  the  parotid  and  its  sup- 
puration. 

Boric  acid  solution  2  per  cent,  to  4  per  cent. 
Dobell's  solution  half  to  quarter  strength. 

Nose. 

Use  sprays  or  cotton  swabs  on  wooden  toothpicks  wet  with  same 
solutions. 

Bowels. 

At  the  beginning  use  calomel  or  salt  or  both. 

Calomel  gr.  %  (0.015  Gm.)  every  fifteen  minutes  until  six  doses  are 

taken  and  follow  in  two  hours  by  Rochelle  or  Epsom  salt  5  ss. 

(15  Gm.). 
During  illness  use  milder  salines,  such  as  citrate  of  magnesia,  Seid- 

litz  powder,  Hunyadi  or  similar  water. 

Fever. 

Rarely  marked. 
Cool  sponges. 

If  accompanied  by  pains  and  aches, 

Acetanilid  gr.  iss.  (0.10  Gm.)  or  phenacetin  gr.  iii  (0.20  Gm.)  every 
three  hours  or  until  relieved. 

Treatment  of  the  Parotitis. 
Often  no  treatment  indicated. 
Pain  and  discomfort. 
Topical  treatment. 
Heat. 

Hot-water  bag. 

Bags  of  hot  salt  or  scouring  sand  of  suitable  shape. 
Dry  poultice. 

Thick  applications  of  absorbent  or  non-absorbent  cotton,  held 
in  place  by  a  bandage. 


MUMPS  553 

Hot  fomentations. 

(For  technique,  see  text.) 
Cold. 
Ice  bag. 

(For  technique  of  application,  see  text.) 
Ice  poultice. 

(For  technique,  see  text.) 
Drugs. 

Ointments  and  liniments  of  doubtful  value. 
Camphorated  oil  (Linimentum  camphorae). 
Belladonna  ointment  official,  or 

3 

Guaiacol,       1  part. 
Vaseline,       10  parts. 
Lanolin,        10  parts. 
M. 

Ichthyol  ointment  (in  vaseline)  10  per  cent,  to  25  per  cent. 
Suppurating  glands. 
Should  be  incised. 

Complications. 

Orchitis. 
Suspension. 

Pillow  stuffed  between  thighs. 

Sheet  of  adhesive  plaster  across  the  thighs,  on  which  scrotum 
may  rest. 

A  "T"  bandage. 
Dry  poultice. 

Abundance  of  non-absorbent  cotton. 
Hot  lead  and  opium  lotion  on  gauze  or  absorbent  cotton. 

Lead  acetate,  gr.  cxx  (8  Gm.). 

Tincture  of  opium,  3ii  (8  c.c.). 

Water  to  make  1  pint  (500  c.c.). 
Keep  bowels  open. 

Ovaries. 
Hot  applications  to  abdomen. 

Mammary  glands. 

Much  such  measures  as  in  orchitis. 

Vulvitis. 

Boric  acid  solutions  2  per  cent,  to  4  per  cent. 
Hot  compresses. 
Hot  sitz  baths. 

Pancreatitis. 

Limit  fat  in  diet. 

Apply  heat  or  cold  over  site  of  pain. 


554  TREATMENT  OF  ACUTE  INFECTIOUS  DISEASES 

Nephritis.    (See  Scarlet  Fever,  Chap.  XVII.)     , 
Arthritis.    (See  Scarlet  Fever,  Chap.  XVII.) 

Nervous  system. 

Bromides  gr.  x  to  gr.  xv  (0.60-1  Gm.)  in  water  three  times  a  day, 
gr.  xv  to  gr.  xxx  (1-2  Gm.)  at  night. 

Meningo-encephalitis. 
Lumbar  Puncture.     (For  technique,  see  Cerebro-spinal  meningitis, 

Chap.  XXV.) 
Ice-bag. 

Severe  headache  or  delirium. 

Morphine  according  to  age. 

(See  Cerebro-spinal  Meningitis,  Chap.  XXV.) 

Sleeplessness. 

Bromides  gr.  xv  to  gr.  xxx  (1-2  Gm.)  in  water  at  night. 
Trional  gr.  x  to  gr.  xv  (0.60-1  Gm".). 

Pain. 

Phenacetin  gr.  iii-v  (0.20-0.30  Gm.). 
Morphine  gr.  1/10  to  gr.  1/8  (0.006-0.008  Gm.). 

Release  from  quarantine. 

Ten  days  after  disappearance  of  local  trouble. 

Convalescence. 
Fresh  air. 
Good  food. 
Iron  if  tonic  is  needed. 

Disinfection. 
Clean  and  ventilate  room. 


CHAPTER  XXIV 

GLANDULAR  FEVER 

THIS  is  essentially  a  disease  of  childhood,  occurring  only  occasionally 
in  adult  life,  and  is  characterized  by  glandular  swelling  especially  of 
the  neck. 

It  begins  as  a  rule  on  the  left  side. 

Axillary  and  inguinal  glands  may  be  involved  and  possibly  some 
of  the  deeper  sets. 

Liver  and  spleen  have  been  found  enlarged  in  some  cases. 

The  adenitis  is  a  result  of  an  acute  infection  but  the  nature  of  the 
infecting  agent  is  not  known. 

Isolation.  The  disease  is  undoubtedly  contagious,  hence,  the  child 
affected  should  be  kept  from  contact  with  the  other  children. 

Suspects  and  children  who  have  been  exposed  should  be  kept  from 
susceptible  individuals  for  a  week  or  ten  days,  for  the  incubation  period 
while  still  undetermined  is  believed  to  be  about  a  week. 

Room  and  Bed.  If  the  patient  be  confined  to  the  bed,  and 
that  is  only  when  fever  or  complications  are  present,  they  should  be 
selected  as  in  other  contagious  diseases. 

Diet.  If  there  is  anorexia  or  vomiting  the  food  is  not  pressed  until 
these  symptoms  have  subsided,  then  the  ordinary  diet  for  febrile  cases 
is  allowed.  See  Chap.  II. 

Water  is  given  freely. 

Bowels.  Calomel,  a  salt  or  castor  oil  should  be  given  at  first.  If 
there  is  much  nausea  or  vomiting  calomel  in  divided  doses  may  be 
used,  e.  g.,  gr.  1/10  (0.006  Gm.)  every  ten  minutes  for  ten  doses,  fol- 
lowed in  two  hours  by  milk  of  magnesia  3ss.  to  i  (15-30  c.c.)  or  liq. 
magnesii  citratis  5iv  to  viii  (120-240  c.c.)  or  if  there  is  no  nausea  the 
salt  alone  or  castor  oil  in  doses  of  3ii  to  5ss.  (8-15  Gm.  or  c.c.)  according 
to  age  may  be  given. 

Throughout  this  disease  the  bowels  should  have  attention,  an 
enema  or  mild  saline  like  liq.  magnesii  citratis  being  given  every  other 
day. 

Care  of  Mouth  and  Nose.  Mild  alkaline  sprays  and  mouth- 
washes  such  as  quarter  strength  DobelTs  solution  or  2  per  cent, 
boric  acid  solution,  or  warm  physiological  salt  solution  may  be 
used. 


556  TREATMENT  OF  ACUTE  INFECTIOUS  DISEASES 

There  is  likely  to  be  a  mild  grade  inflammation  of  the  tonsils  or  phar- 
ynx, but  bearing  no  relation  to  the  adenitis. 

That  the  glands  sometimes  suppurate  and  that  otitis,  parotitis,  ne- 
phritis has  been  known  to  occur,  accentuates  the  necessity  for  care  of 
the  mouth,  the  possible  source  of  such  complications. 

Toxemia.  At  the  onset  the  usual  malaise,  headaches,  pains  and 
fever  of  an  infection  may  occur.  If  these  are  marked  small  doses  of 
acetphenetidin  (phenacetin)  gr.  i  to  gr.  ii  (0.060-0.12  Gm.)  every  two  to 
three  hours  or  aspirin  gr.  ii  to  gr.  v  (0.12-0.30  Gm.)  or  salicin  gr.  iii 
to  gr.  x  (0.20-0.65  Gm.)  at  the  same  intervals  may  be  used  to  relieve 
discomfort. 

Fever.  The  temperature  is  not  high  as  a  rule  but  may  reach 
104°  F.  or  105°  F.  Sponging  with  cool  water  may  make  the  patient 
more  comfortable. 

Adenitis.  The  large  tender  glands  are  the  "hall-marks"  of  the 
disease.  They  become  obvious  after  twenty-four  to  forty-eight  hours 
and  increase  to  the  si^ze  of  pecan  nuts,  remaining  discreet.  As  a  rule 
they  begin  high  up  under  the  sterno-cleido  mastoid  of  the  left  side 
spreading  later  to  the  right  side.  They  cause  the  patient  to  hold  the  neck 
stiff  and  at  times  to  experience  some  pain  on  swallowing;  moreover, 
these  glands  are  very  sensitive  to  the  touch.  All  the  glands  of  the  neck 
are  likely  to  become  involved,  even  "a  fine  network  of  glands  about 
1  c.c.  in  diameter,  like  the  spots  placed  at  the  intersection  of  the  strands 
of  a  large  mesh  veil,  covers  the  entire  lateral  and  posterior  aspects  of  the 
neck,"  as  Haas  picturesquely  puts  it.  Beside  the  superficial  glands, 
cervical,  axillary,  inguinal,  epitrochlear,  the  mesenteric  causing  pain  in 
the  region  of  umbilicus,  bronchial  and  mediastinal  perhaps  causing  the 
croupy  cough,  may  be  involved. 

Relief  of  pain  and  discomfort  may  be  sought  in  the  measures  appli- 
cable to  adenitis  from  other  causes,  namely,  heat,  in  the  shape  of  hot 
fomentations  (see  Scarlet  Fever,  Chap.  XVII)  or  poultices,  or  hot-water 
bag  or  cold  in  the  shape  of  the  ice-bag  or  cold  compresses.  (See  Scarlet 
Fever,  Chap.  XVII.) 

Ichthyol  is  a  favorite  application  in  25  per  cent,  to  50  per  cent, 
in  vaseline. 

Very  rarely  a  gland  may  suppurate,  when  it  is  to  be  treated  surgically 
by  incision  and  evacuation  of  pus. 

For  glands  which  are  slow  in  receding  Haas  recommends  Fowler's 
solution  (liq.  potassii  arsenitis)  m.  ii  to  x  (0.12-0.65  Gm.)  in  water 
three  times  a  day. 

Complications.  Beside  the  occurrence  of  suppuration  in  an  af- 
fected gland,  otitis  media  and  nephritis  are  the  only  serious  compli- 


GLANDULAR  FEVER  557 

cations,  fortunately  rare.  They  are  treated  as  under  circumstances. 
(For  nephritis,  see  Scarlet  Fever,  Chap.  XVII;  for  otitis,  see  Scarlet 
Fever,  Chap.  XVII.) 

The  course  is  usually  mild  and  although  the  glands  do  not  resolve 
for  two  to  four  weeks  the  malaise  and  fever  disappear  after  a  few  days, 
though  slight  recrudescences  may  occur  with  involvements  of  other 
glands  or  recrudescences  of  the  process  in  the  same  glands  or  set  of  glands 
with  febrile  manifestation  may  be  repeated  several  times.  The  case 
impresses  one  at  times  as  a  streptococcus  invasion  and  certain  bacterial 
findings  in  the  throat  and  suppurating  glands  strengthen  the  impression. 
Again  the  condition  is  at  times  difficult  to  differentiate  from  mild  scarlet 
fever  for  erythematous  rashes  in  glandular  fever  are  occasional  happen- 
ings. The  late  glandular  relapses  and  nephritis  increase  the  perplexity 
of  the  diagnostician. 

Convalescence.  Severe  secondary  anemia  may  occur  and  in  severe 
cases  may  be  quite  striking.  Iron  may  be  administered  for  this. 

In  the  younger  children  the  bitter  wine  of  iron  (Vinum  ferri  amarum) 
3i  to  3ii  (4-8  c.c.)  three  times  a  day,  or  in  older  children  Vallet's  mass 
(Massa  ferri  carb.)  gr.  ii  to  gr.  v  (0.12-0.30  Gm.)  three  times  a  day,  or 
Blaud's  pill  (Pil.  ferri  carb.)  in  same  doses. 

As  a  general  tonic  small  doses  of  the  tincture  of  nux  vomica,  m.  ii 
to  m.  x  (0.12-0.65  c.c.)  or  strychnine  sulphate  gr.  1/150  to  gr.  1/60 
(0.00045-0.001  Gm.)  three  times  a  day  according  to  age. 

Fresh  air  and  good  food  are  the  best  tonics. 

Prognosis  is  good.  The  only  cases  to  be  dreaded  are  those  compli- 
cated by  Nephritis. 

Prophylaxis.  We  know  so  little  about  the  mode  of  conveyance 
of  this  disease  and  indeed  of  its  true  nature  that  we  are  unable  to  effect 
efficient  prophylactic  measures  beyond  isolation  of  the  sick  child  in  the 
family. 

SUMMARY 
Treatment 
Isolation. 

The  child  should  be  kept  from  contact  with  other  children. 
Suspects  and  children  who  have  been  exposed  should  be  kept  from 
susceptible  individuals,  a  week  or  ten  days. 

Room. 
Light  and  airy. 

Diet. 

Do  not  force  feeding  during  period  of  anorexia. 
Later  follow  rules  in  Chap.  II. 
Give  water  freely. 


558  TREATMENT  OF  ACUTE  INFECTIOUS  DISEASES 

Bowels. 

Calomel  gr.  1/10  (0.006  Gm.)  every  ten  minutes  for  ten  doses,  fol- 
lowed by 

Milk  of  magnesia  5ss.-i  (15-30  c.c.)  or 

Liquor  magnesii  citratis  5iv-viii  (120-240  c.c.)  or  if  there  is  no  nausea 
A  salt  alone,  or 
Castor  oil  3ji-iv  (8-15  c.c.). 
Enema  or  mild  saline  every  other  day. 

Mouth  and  throat. 

Washes  and  sprays  of 

Two  per  cent,  to  4  per  cent,  boric  acid  solution. 
DobelPs  solution,  quarter  strength. 

Warm  physiological  salt  solution  (3i  of  common  salt  to  1  pint,  4  Gm. 
to  500  c.c.). 

Toxemia. 

Pains  and  aches  of  sthenic  period. 

Phenacetin  gr.  i-gr.  ii  (0.060-0.12  Gm.)  every  two  or  three  hours 

or 

Aspirin  gr.  ii  to  gr.  v  (0.12-0.30  Gm.)  at  same  intervals  or 
Salicin  gr.  iii  to  gr.  x  (0.20-0.65  Gm.). 

Fever. 
Sponging  with  cold  water. 

Adenitis. 

Heat. 

Fomentations. 
Poultices. 


Hot-water  bottle 


(See  Scarlet  Fever,  Chap.XVII.) 


Cold. 

Ice-bag. 

Cold  compress. 
Ichthyol  25  per  cent,  to  50  per  cent,  ointment  over  the  affected 

glands. 

Surgery. 
Incision  of  suppurating  glands. 

Delayed  resolution. 

Fowler's  solution  (Liq.  potassi  arsenitis)  m.  ii  to  m.  x  (0.12-0.65 
Gm.)  three  times  a  day. 

Complications. 
Rare. 

Nejhritis.  }  (See  Scarlet  Fever>  Chap'  XVIL) 


GLANDULAR  FEVER  559 

Convalescence. 

Anemia. 
Iron. 
Vinum  ferri  amarum  (Bitter  wine  of  iron)  3i  to  3ii  (4^8  c.c.) 

three  times  a  day  for  young  children. 
Vallet's  mass  (Massa  ferri  carbonatis)  gr.  ii  to  gr.  v  (0.12-0.30 

Gm.)  or 

Pil.  ferri  carbonatis  (Blaud's)  same  doses. 
Tr.  nucis  vomicse  m.  ii  to  m.  x  (0.12-0.65  c.c.)  three  times  a  day 

or 
Strychnine  sulphate  gr.  1/150  to  gr.  1/60  (0.00045-0.001  Gm.)  three 

times  a  day. 
Fresh  air. 
Good  food. 

Prophylaxis. 
Isolation  of  sick  child. 


CHAPTER  XXV 

CEREBRO-SPINAL  MENINGITIS 

A  GENERAL  infection,  due  to  a  definite  organism,  the  diplococcus 
of  Weichselbaum  (diplococcus  intracellularis  meningitidis),  the  char- 
acteristic symptomatology  of  which  is  referred  to  the  site  of  its  greatest 
local  activity,  the  meninges  of  the  brain  and  spinal  cord. 

It  is  one  of  the  few  diseases  for  which  a  specific  treatment  has  been 
achieved  and  for  this  reason  an  etiological  diagnosis  is  important,  that  is, 
the  recognition  of  the  causal  organism,  which  may  be  recovered  from  the 
blood  before  it  appears  in  the  spinal  cord  or  in  some  instances  before 
there  are  cerebro-spinal  symptoms.  Indeed,  in  the  presence  of  an  epi- 
demic, cases  of  meningococcic  septicemia  have  been  determined  which 
never  developed  cerebro-spinal  symptoms  even  though  no  intraspinal 
therapy  had  been  used. 

It  is  now  recognized  that  there  are  three  groups  of  meningococci,  the 
normal  or  regular,  the  para  or  irregular  and  the  intermediary  group  which 
cross  agglutinates  with  the  other  two.  The  importance  of  this  lies  in  the 
appreciation  of  the  fact  that  unsatisfactory  serum  therapy  may  be  due 
to  an  insufficient  representation  of  the  immune  bodies  produced  by  a 
certain  group  in  the  polyvalent  serum  which  is  used. 

Distribution  of  the  Family.  One  has  to  consider  the  possibility 
of  infection  of  other  members  of  the  family  and  the  danger  which  other 
members  of  the  family  may  be,  in  the  capacity  of  carriers,  to  those 
outside. 

So  rarely  did  fresh  cases  break  out  in  the  wards  of  hospitals  admitting 
these  cases  and  so  rarely  did  physician  or  nurse  acquire  the  disease 
from  the  patient,  that  for  a  long  time  it  was  assumed  that  the  disease 
was  not  contagious  and  even  to-day  such  facts  as  these  and  that  in 
large  epidemics,  in  the  vast  majority  of  instances,  only  one  member 
of  a  family  is  affected  is  hard  to  understand,  but  more  careful  study 
and  experimentation  has  demonstrated  the  contagiousness  of  the  disease 
and  the  important  role  of  the  carrier.  It  is  because  of  the  high  mortality 
of  the  disease  and  the  dread  possibilities  even  in  case  of  survival,  that 
Public  Health  authorities  have  included  it  among  the  contagious  and 
reportable  diseases  and  it  becomes  incumbent  upon  us  to  pursue  every 
means  to  prevent  our  patient  from  being  the  source  of  yet  another  case. 

The  insistence  on  that  isolation  that  has  become  habitual  in  the  case 


CEREBRO-SPINAL  MENINGITIS  561 

of  scarlet  fever  has  not  yet  been  voiced  by  writers  on  the  subject,  but 
it  seems  to  me  such  isolation  is  as  imperative  in  the  case  of  the  one 
as  the  other,  for  the  high  mortality  and  the  wretched  sequences  of  the 
one  balance  the  high  incidence  of  the  other. 

The  patient,  then,  should  be  insolated  with  nurse  or  attendant. 

Other  children  should  be  removed,  if  possible,  and  to  quarters  where 
they  shall  not  come  in  contact  with  children,  for  though  they  may  not 
develop  the  disease  they  may  still  be  carriers  of  the  infection  capable 
of  infecting  others. 

How  long  these  "contacts"  should  be  isolated  is  a  difficult  matter 
to  decide.  The  incubation  period  has  not  been  very  well  determined, 
but  the  average  time  seems  to  be  7-14  days. 

However,  some  of  the  observations  suggest  that  in  some  cases,  at 
least,  it  may  last  a  month,  though  usually  it  is  a  much  shorter  period. 
If  laboratory  facilities  are  at  hand  suspects  should  have  their  nasal 
secretions  examined  to  determine  whether  or  no  they  harbor  the  dip- 
lococcus  in  the  nasal  passages.  If  the  children  cannot  be  removed, 
communication  direct  or  indirect  with  the  patient  must  be  carefully 
avoided.  Adults,  though  still  susceptible,  are  far  less  so  than  children, 
but,  with  the  exception  of  those  members  of  the  family  whose  presence 
in  the  sick-room  is  necessary  to  the  patients,  no  contact  with  the  patient 
should  be  allowed. 

Adults  in  the  family  must  remember  that  infection  of  fresh  cases 
has  occurred  curiously  frequently  through  a  third  person;  hence,  they 
should  avoid  contact  with  children.  If  the  adults  come  in  contact  with 
children  in  the  course  of  their  daily  duty,  they  should  remove  from  the 
environment  of  the  patient  and  observe  a  period  of  isolation,  as  in  the 
case  of  the  children  cited  above. 

In  all  cases  where  possible  these  "contacts"  should  have  their  nasal 
secretions  examined  to  determine  whether  they  are  "carriers"  or  no, 
and,  if  so,  should  avoid  children  at  least  as  long  as  the  epidemic  lasts. 
Indeed  with  knowledge  that  the  carrier  is  a  menace  to  whomsoever 
he  comes  in  contact  with,  it  would  seem  reasonable  to  insist  on  an  isola- 
tion of  such  carriers  until  they  are  free  from  the  infection.  This  was 
the  rule  insisted  on  in  camps  during  the  recent  war. 

The  number  of  people  who  in  contact  with  the  sick  become  "carriers" 
is  surprisingly  large,  Elser  and  Huntoon,  during  an  epidemic,  deter- 
mined that  at  least  70  per  cent,  were  in  this  class. 

Apart  from  the  epidemic  the  "carriers"  were  rare,  but  occasionally 
a  person  becomes  a  permanent  "carrier"  and  can  convey  the  disease. 

That  so  few  of  the  persons  harboring  the  organisms  in  this  manner 
become  themselves  the  victim  of  the  disease  would  bespeak  the  prob- 


562  TREATMENT  OF  ACUTE  INFECTIOUS  DISEASES 

ability  of  some 'Other  factor  in  the  determination  of  the  infection  and 
with  our  present  views  of  infection,  we  seek  it  in  the  lowering  of  the 
individual's  resistance.  For  this  reason,  it  becomes  doubly  important 
to  avoid  during  an  epidemic  minor  infections,  such  as  rhinitis,  tonsil- 
litis, etc.,  at  other  times  trivial,  lest  it  afford  the  opportunity  for  the 
diploccus  of  Weichselbaum  to  gain  entrance  into  the  blood. 

" Contacts"  should  use  a  mild  spray  for  the  throat  and  nose,  such 
as  2  per  cent,  boric  acid  or  Dobell's  solution,  quarter  strength,  or  one 
of  the  mild  equivalents  on  the  market.  Under  no  circumstances  should 
strong  astringents  or  strong  bactericidal  solutions  be  used,  lest  the 
irritation  set  up  in  the  mucous  membrane  lessen  the  resistance  of  the 
structures  to  the  invasion  of  the  infecting  organism. 

Nurse.  The  nurse  from  her  intimate  contact  with  the  patient 
is  very  likely  to  become  a  carrier.  For  this  reason  she  should  avoid 
coming  into  contact  with  children  during  her  hours  off  duty  and  remem- 
ber that  coughing,  sneezing  and  kissing  are  means  by  which  the  organ- 
ism may  readily  be  conveyed  to  another. 

She  should  clean  her  hands  and  face  with  soap  and  water  and  alcohol 
or  bichloride  1  to  1,000  and  spray  her  nose  and  throat  before  going  out. 
As  a  precautionary  measure  she  should  use  one  of  the  mild  sprays 
advised  above  from  time  to  time  while  on  duty. 

Physician.  The  physician  has  always  to  think  about  the  possi- 
bility of  carrying  the  disease;  but,  fortunately,  it  is  rarely  that  he  can  be 
shown  to  have  done  so.  The  organism  is  readily  killed  by  drying  and 
exposure  to  sunlight  and  the  physician's  contact  with  the  patient  is 
brief.  He  should,  however,  carefully  cleanse  his  face  and  hands  with 
soap  and  water  and  alcohol  or  1  to  1,000  bichloride  and  spray  his  throat 
and  nose  before  leaving  the  case  for  another  call  and  should  make  his 
stay  with  the  patient  as  brief  as  is  compatible  with  the  performance  of 
his  duties.  He  should,  moreover,  spend  some  period  in  the  open  air 
before  another  visit  is  made  and  endeavor  not  to  make  his  next  call 
upon  a  child. 

Room.  A  large  well  ventilated  room,  free  of  furnishings,  with 
bare  floors  or  floors  covered  with  some  cheap  material  which  may  be 
destroyed  after  the  patient  has  been  removed,  such  as  carpet  lining 
covered  with  unbleached  muslin,  should  be  chosen.  A  verandah  lead- 
ing from  the  room  and  a  bath  room  immediately  contiguous  are  ad- 
vantages. Light  and  air  are  potent  allies  in  destroying  the  infection. 

If  the  light  hurts  the  eyes,  suitable  screens  may  be  arranged  to  protect 
the  patient. 

Avoidance  of  noise,  jars,  irritations  of  all  kinds  are  to  be  observed 
on  account  of  the  marked  hypersensitiveness  of  the  patient. 


CEREBRO-SPINAL  MENINGITIS  563 

Precautions  in  the  Sick-Room.  Since  the  infective  material  is 
known  to  reside  in  the  nasal  and  oral  secretions,  all  these  should  be 
received  on  rags  or  muslin  that  may  be  destroyed  or  into  vessels  in 
which  they  may  be  disinfected  with  carbolic  1  in  20  or  bichloride  of 
mercury  1  in  500. 

The  thermometer  should  be  left  in  the  sick-room  and  kept  in  carbolic 
2  per  cent,  to  5  per  cent,  or  in  formalin. 

Eating  utensils  should  be  boiled,  but  if  sent  out  of  the  sick-room  for 
that  purpose  should  be  previously  soaked  in  1  to  20  carbolic  acid  for 
twenty  minutes  to  a  half  hour.  Urinals,  bed-pans,  etc.,  should  be 
disinfected  with  1  to  20  carbolic  (phenol)  or  1  to  500  bichloride,  while 
clothes  should  be  soaked  overnight  in  1  to  50  to  1  to  20  phenol  and  then 
boiled  a  hah"  hour  to  an  hour  before  being  put  in  the  family  wash. 

Bed.  The  bed  is  to  be  prepared  in  the  usual  way.  It  is  doubly 
imperative  to  avoid  wrinkles,  crumbs,  dampness  of  the  sheets  from 
secretions,  because  of  the  tendency  to  form  bed-sores  in  this  condition. 
If  the  emaciation  is  marked,  the  nutrition  of  the  skin  badly  impaired 
or  any  hint  of  a  bed-sore  observed,  it  is  well  to  have  a  water-bed  or  air 
mattress. 

The  extreme  sensitiveness  of  the  patient  to  cold  makes  a  demand 
on  more  clothing  than  in  other  febrile  conditions. 

The  Patient.  Much  depends  on  the  skill,  fidelity  and  patience  of 
the  nurse  in  attendance.  The  demands  are  often  continuous  and  in- 
sistent, the  pains  and  discomforts  sacrifice  rest  and  sleep  and  so  strength. 
For  this  reason  and  because  of  the  long  course  many  of  the  cases  take, 
all  should  be  done  to  economize  the  strength  and  health  of  the  nurse, 
in  the  choice  of  a  room,  the  nearness  of  the  bath  room,  the  quiet  and 
seclusion  of  her  own  rest  hours.  Two  nurses  should  be  on  the  case,  one 
for  night  and  the  other  for  day. 

The  patient  should  wear  a  nightgown  of  light  flannel  or  if  this  is 
irritating,  cotton.  It  should  be  open  all  the  way  down  in  front,  to  make 
the  necessary  examinations  possible  with  the  least  disturbance  to  the 
patient. 

Diet.  During  the  early  hours  or  days  of  the  infection  when  the 
fever  is  high  and  the  evidences  of  intoxication  acute,  the  feeding  is 
not  to  be  urged  against  the  anorexia,  but  as  the  disease  is  peculiarly 
associated  with  emaciation  and  is  likely  to  be  long  drawn  out,  the  feed- 
ing after  the  first  few  days,  even  in  the  presence  of  fever  or  stupor  is  to  be 
increased,  given  at  regular  two  and  three  hour  intervals. 

Often  at  a  later  stage  the  appetite  is  keen,  if  not  ravenous,  and  it 
should  be  indulged  abundantly. 

At  first  the  food  should  be  liquid,  milk  or  one  of  the  milk  prepara- 


564  TREATMENT  OF  ACUTE  INFECTIOUS  DISEASES 

tions,  such  as  buttermilk,  koumys  or  if  there  is  any  gastric  disturbance, 
skim  milk,  whey  or  peptonized  milk. 

Cereal  gruels  or  well  cooked  cereals  and  farinaceous  foods,  such  as 
arrowroot,  barley,  rice,  cornstarch,  farina,  imperial  granum,  cornmeal, 
oatmeal,  if  it  occasions  no  gas  formation,  jellies  of  barley  flour,  tapioca, 
sago,  milk  toast,  veal,  mutton,  chicken  or  beef  broths,  may  be  used. 
These  may  be  thickened  with  barley  or  other  flour.  Later,  ice  cream, 
eggs,  custard,  potatoes,  oysters,  scraped  meat,  pureed  peas,  small  string 
beans  or  spinach  and  asparagus  tips. 

In  infancy  the  modification  of  the  milk  is  to  be  changed  to  a  somewhat 
greater  dilution. 

In  stupor  or  in  case  the  patient  cannot  swallow,  the  feeding  must 
be  by  gavage  or  nasal  feeding;  it  is  well  to  change  occasionally  from 
one  to  the  other.  As  a  rule  in  the  older  patients  the  oral  route  is  prefer- 
able, while  in  children  the  nasal  is  the  better. 

Drinks.  Water,  fruit  juices  in  water,  carrying  sugar,  not  merely 
to  sweeten  but  to  add  materially  to  the  food  ingested,  are  administered. 

It  cannot  be  too  much  emphasized  that  the  drinks  should  be  pushed. 
The  demands  of  the  tissues  are  great  and  the  apathy  of  the  patient 
defeats  these  demands  unless  the  nurse  offers  fluids  frequently  and  urges 
the  patient  to  drink. 

The  feeding  should  be  at  intervals  of  two  to  three  hours  and  as  the 
case  becomes  subacute,  some  definite  idea  of  the  actual  amounts  of 
heat  units  ingested  and  energy  needs  of  the  case  must  be  kept  in  mind. 
(See  Chap.  II.) 

Skin.  A  cleansing  bath  of  warm  water  and  soap  should  be  given 
each  day.  Bed-sores  are  prone  to  occur.  The  emaciation  accentuat- 
ing the  bony  prominences  makes  it  imperative  to  relieve  the  pressure 
upon  these  points  by  frequent  change  of  position,  mechanical  devices 
such  as  rings  and  cushions,  by  keeping  these  parts  scrupulously  clean 
and  dry  and  by  frequent  rubbing  to  keep  the  circulation  active  in  the 
skin  and  by  the  use  of  alcohol  rubs  and  talcum  powder,  by  avoiding 
wrinkles  in  the  sheets,  crumbs  in  the  bed  and  by  most  gentle  handling. 
If  sores  are  imminent  the  air  mattress  or  water-bed  should  be  used  and 
increasing  care  given  the  threatened  parts. 

Mouth  and  Nose.  In  the  care  of  the  mouth  and  nose  in  this 
disease  two  things  are  to  be  kept  in  mind:  first,  the  comfort  and  welfare 
of  the  patient;  second,  the  danger  his  secretions  entail  to  others. 

The  mouth  should  be  cleansed  by  having  the  patient  rinse  his  mouth 
with  plain  water,  followed  by  2  per  cent,  to  4  per  cent,  boric  acid  solu- 
tion or  DobelPs  solution,  half  to  quarter  strength,  used  as  a  mouth 
wash  or  spray.  After  eating,  the  nurse  should  see  that  all  dead  spaces  in 


CEREBRO-SPINAL  MENINGITIS  565 

the  mouth  and  interstices  of  the  teeth  are  freed  from  food  particles  by 
the  use  of  small  cotton  swabs  on  wooden  tooth  picks  or  other  simple 
applicator,  wet  with  the  same  solution. 

If  there  is  sordes  on  lips  and  teeth  or  the  tongue  is  heavily  coated, 
half  strength  official  hydrogen  peroxide  may  be  applied  to  soften  the 
deposit  and  in  case  of  the  tongue  the  edge  of  a  whalebone  or  equivalent 
instrument  may  be  used  as  a  scraper,  then  followed  by  the  solutions 
mentioned.  For  a  dry  mouth  equal  parts  of  2  per  cent,  boric  acid  solu- 
tion and  albolene  with  a  little  lemon  juice  is  excellent. 

The  nose  may  be  sprayed  by  the  same  solutions. 

All  secretions  should  be  destroyed,  preferably  by  burning,  and 
danger  in  handling  these  secretions  should  be  kept  in  mind  by  the  nurse, 
who  should  carefully  wash  her  hands  and  have  recourse  to  an  antiseptic, 
such  as  alcohol  or  1  to  1,000  bichloride  after  the  ministrations. 

Eyes.  There  is  likely  to  be  a  conjunctivitis  of  mild  or  moderate 
grade.  It  is  believed  that  these  secretions,  too,  are  infectious  and  for 
that  reason  they  should  be  destroyed  with  the  same  care  as  in  the  case  of 
nasal  secretions.  For  the  eyes  nothing  is  better  than  mild  boric  acid 
washes  of  2  per  cent,  strength. 

Bowels.  The  bowels  should  be  freely  opened  at  the  beginning  of 
the  illness  and  attention  given  them  throughout  the  course. 

For  an  initial  catharsis,  calomel  in  doses  of  gr.  1/4  (0.015  Gm.)  every 
quarter  hour  for  four  or  five  doses,  followed  in  two  or  three  hours  by  milk 
of  magnesia  in  dose  of  3ss.  (15  c.c.)  is  suitable  and  is  especially  good  in 
cases  of  vomiting,  in  which  the  divided  doses  of  calomel  is  credited  with 
an  antiemetic  action  and  the  milk  of  magnesia  acts  as  a  gastric  sedative. 
If  there  is  no  vomiting,  castor  oil  3 ii  to  iv  (8-15  c.c.)  or  Rochelle  salt, 
3ii  to  iv  (8-15  Gm.)  may  be  used. 

Later,  milk  of  magnesia,  3ss.  (15  c.c.),  Liquor  Magnesii  Citratis, 
Siv  to  viii  (180-240  c.c.),  Hunyadi  water,  3iii  to  vi  (90-180  c.c.),  or 
cascara  preparations  may  be  given,  or  an  enema  may  effect  the  purpose. 
If  there  is  much  vomiting  during  the  course,  the  enema  will  be  the  better 
choice  of  methods.  If  hyperaesthesia  is  very  marked,  the  oral  adminis- 
tration may  be  less  annoying. 

Treatment  of  Nausea.  Almost  invariably  vomiting  occurs  with 
the  onset  of  the  disease.  Sometimes  it  continues  for  days.  It  is  also 
a  feature  of  the  long-standing  cases. 

Not  only  is  the  vomiting  exhausting  in  itself,  but  it  makes  feeding 
difficult.  The  vomiting  is  probably  central  and  may  occur  without 
nausea.  Measures  directed  at  the  stomach  itself  would  seem  then  to 
promise  little  unless  some  gastric  irritability  in  addition  existed.  We 
may,  however,  try  such  expedients  as  cracked  ice,  a  mustard  paste,  one 


566  TREATMENT  OF  ACUTE  INFECTIOUS  DISEASES 

of  mustard  to  four  of  flour,  to  the  pit  of  the,  stomach,  sodium  bicar- 
bonate gr.  x-xv  (0.60-1  Gm.)  in  a  little  water,  bismuth  subnitrate  gr. 
x-xv  (0.60-1  Gm.)  stirred  in  a  little  water,  or  cerium  oxalate  gr.  iii  to  v 
(0.20-0.30  Gm.)  in  the  same  way,  or  all  in  combination,  bromides  in 
5-15  grain  (0.33-1  Gm.)  doses. 

Feeding  is  sometimes  possible  by  the  stomach  tube,  when  other- 
wise rejected. 

Treatment  of  symptoms. 

As  one  might  anticipate  from  the  nature  of  the  lesion,  symptoms 
referable  to  cerebral  irritation  are  dominant. 

Restlessness,  delirium  and  sleeplessness  demand  attention. 

The  application  of  the  ice-cap  or  ice-coil  is  a  helpful  measure  and 
the  sedative  effects  of  warm  sponge  baths  are  to  be  kept  in  mind. 

Of  the  drugs  in  the  milder  cases  one  has  recourse  to  bromides,  for 
the  more  severe,  codeine  and  morphine  or  even  hyoscine  hydrobromide 
in  doses  determined  by  age  and  severity,  e.  g.,  bromides  gr.  iii-v  (0.20- 
0.30  Gm.)  three  times  a  day  at  one  year;  gr.  v-x  (0.30-0.60  Gm.)  at  five 
years;  for  adults  gr.  15-20  (grams  1-1.3). 

Codeine  sulphate  gr.  1/60-1/30  (0.001-0.002  Gm.)  at  one  year  and  gr. 
1/10-1/5  (0.006-0.012  Gm.)  at  five  years;  for  adults  gr.  1/8-1  (0.008- 
0.060  gram)  or  in  severe  cases  morphine  gr.  1/200-1/100  (0.0003-0.0006 
Gm.)  at  one  year  to  gr.  1/30-1/20  (0.002-0.003  Gm.)  at  five  years.  For 
adults  gr.  1/8-1/4  (0.008-0.004  grams). 

Hyoscine  hydrobromide  to  a  child  of  five  years  may  be  given  if  above 
drugs  faH,  in  doses  of  gr.  1/800-gr.  1/400  (0.000075-0.00015  Gm.) ;  gr. 
1/200-1/100  (0.0003-0.0006  gram)  to  an  adult. 

Convulsions.  Slight  twitchings  may  be  controlled  by  the  use 
of  chloral,  best  given  by  the  rectum  in  small  amounts  of  warm  milk 
reinforced  by  bromides  by  mouth  or  rectum. 

Severe  convulsions  require  morphine. 

The  circulation,  attacked  by  the  toxins  of  the  disease  and  feeling 
the  effects  of  their  action  and  that  of  intracranial  pressure  on  the  medul- 
lary centres,  needs  support  and  yet  its  impairment  is  not,  as  a  rule,  as 
great  as  one  might  anticipate. 

For  continuous  support  we  rely  on  digitalis  or  strophanthin  or  for 
immediate  demands  on  caffeine. 

Do  not  use  strychnine  on  account  of  its  exciting  effects  on  motor 
centres. 

Dose.  In  adults  digitalis  is  given  in  the  form  of  the  infusion  3ss. 
(15  c.c.)  or  m.  xxx  of  the  tincture  (2  c.c.)  three  times  a  day  for  three  or 
four  days,  or  in  emergency  strophanthin  gr.  1/120-1/90  (0.0005-0.00075 
Gm.)  into  vein  or  muscle,  followed  by  digitalis  as  mentioned.  Caffeine 


CEREBRO-SPINAL  MENINGITIS  567 

in  the  form  of  a  soluble  salt  gr.  v  (0.30  Gm.)  every  four  to  two  hours. 
Children  are  given  smaller  doses  according  to  age  or  weight. 

It  is  believed  by  certain  investigators  that  brain  volume  may  be 
lessened  by  the  use  of  hypertonic  glucose  solution.  If  this  be  true  those 
symptoms  referable  to  increased  intracranial  pressure,  such  as  restless- 
ness, delirium,  sleeplessness  and  to  a  certain  extent  circulatory  distur- 
bances should  be  relieved  by  the  measure.  They  advise  giving  intraven- 
ously a  25  per  cent,  glucose  in  the  amount  of  250  c.c.  taking  one  hour  for 
the  administration.  The  solution  should  be  sterilized  in  an  autoclave. 
This  injection  is  to  be  repeated  at  12-hour  intervals  until  evidence  of 
reduction  of  intracranial  pressure  is  observed. 

Bladder.  Distension  is  likely  to  occur  in  the  stuporous  and 
incontinence  is  likely  to  mean  an  overflow. 

Evidence  of  such  a  state  of  affairs  is  to  be  sought  for  by  palpation 
and  percussion  and  efforts  at  relief  afforded  by  the  application  of  hot 
stupes  over  the  hypogastrium  or  if  this  fails  by  the  use  of  the  catheter. 

Drug  Treatment.  There  is  no  drug  that  can  be  called  specific; 
though  urotropin  has  been  greatly  recommended  with  the  hope  that  its 
presence  in  the  cerebro-spinal  fluid  (which  is  demonstrable)  might 
prove  bactericidal.  Our  knowledge  of  the  action  of  urotropin,  however, 
points  to  its  efficiency  as  a  bactericide  only  in  the  presence  of  an 
acid  medium.  It  probably  has  no  action  whatsoever  in  the  alkaline 
cerebro-spinal  fluid.  It  is  still  recommended  but  with  diminishing 
fervor. 

Specific  Treatment.  Upon  the  determination  of  the  diplococcus 
intracellularis  meningitidis  as  the  causative  agent  of  the  disease,  there 
followed  efforts  to  find  a  specific  substance  to  combat  it  and  its  effects. 
The  fact  that  the  toxic  substance  of  the  organism  was  found  to  belong 
to  that  class  of  poisons  known  as  endotoxins,  i.  e.,  toxins  bound  up  in 
the  body  of  the  organism  itself  and  not  excreted  by  it  as  is  the  case  with 
the  diphtheria  bacillus,  and  the  fact  that  antitoxins  to  this  kind  of  toxin 
have  not  been  determined  made  the  outlook  for  success  in  this  direction 
no  better  than  in  the  case  of  other  diseases  due  to  endotoxin-bearing 
bacteria,  such  as  pneumonia,  streptococcsemia,  etc. 

The  effort  was  made,  however,  to  obtain  an  active  serum  by  the  im- 
munization of  animals  with  the  meningococcus  and  as  the  first  efforts 
at  treatment  followed  the  usual  lines  of  subcutaneous  or  intravenous 
injections,  disappointing  results  ensued,  until  the  suggestion  to  inject 
the  serum  into  the  spinal  canal  reaped  a  rich  reward. 

In  spite  of  theoretical  considerations  the  serum  does  seem  to  have 
some  antitoxic  power,  but  in  no  sense  owes  the  total  of  its  efficacy  to 
this.  What  it  does  seem  to  do  is  to  inhibit  the  growth,  induce  the  death 


568  TREATMENT  OF  ACUTE  INFECTIOUS  DISEASES 

and  initiate  the  disintegration  of  the  diplococcus,  while  at  the  same 
time  it  has  opsonic  qualities,  encouraging  phagocytic  activity. 

Mode  of  Preparation.  The  serum  is  obtained  by  injecting  into 
animals  (the  horse  is  the  animal  now  preferred)  at  weekly  intervals, 
increasing  quantities  of  the  meningococcus.  At  first  dead  bodies  are 
used  and  it  is  found  that  better  results  ensue  if  the  autolysate  (products 
of  self-digestion)  of  the  organism  is  used  alternately  with  the  diplococci 
themselves.  The  whole  course  takes  from  four  to  six  months.  Later 
the  live  diplococci  take  the  place  of  dead  ones. 

Blood  is  then  withdrawn  from  a  vein,  the  cells  separated  from  the 
serum  and  the  latter  preserved  for  use. 

Dosage.  The  dosage  is  limited  only  by  the  capacity  of  the  spinal 
canal.  The  dose  may  be  taken  at  30  c.c.  with  these  modifications: 
(1)  That  if  more  than  this  amount  of  cerebro-spinal  fluid  can  be  with- 
drawn from  the  spinal  canal,  an  equal  amount  of  the  serum  should  re- 
place it.  (2)  That  if  less  than  30  c.c.  is  withidrawn  from  the  canal,  the 
dose  should  approximate  30  c.c.  as  near  as  possible  without  inducing 
pressure  symptoms  or  rather  without  forcing  against  rapidly  increasing 
resistance.  Doses  less  than  30  c.c.  are  much  less  efficacious. 

Sophian  as  a  result  of  his  studies  lays  great  stress  on  the  blood  press- 
ure. He  takes  a  fall  of  20  mm.  as  an  indication  for  halting  the  injection. 
Then  he  waits  a  few  minutes  and  tries  again;  if  further  fall  occurs  he 
stops,  as  he  has  noted  that  after  a  fall  of  20  mm.  a  further  fall  is  apt  to 
be  precipitate  and  dangerous.  He  gives  the  average  dose  as  controlled 
by  blood  pressure  to  be 

1 — 5    years 2 — 12  c.c.  serum 

5 — 10  years 5 — 15  c.c.  serum 

10 — 15  years 10 — 20  c.c.  serum 

15 — 20  years 15 — 30  c.c.  serum 

20  years  and  over 20 — 40  c.c.  serum 

occasionally  more 
(Forchheimer's  Therapeusis  of  Internal  Diseases.) 

This  precaution  of  Sophian 's  is  rarely  observed  in  practice  and  experience 
does  not  emphasize  the  necessity. 

Frequency.  The  dose  should  be  repeated  each  day  for  three 
or  four  days  or  longer;  longer  if  the  diplococci  are  found  on  the  stained 
spread  of  the  cerebro-spinal  fluid  withdrawn  to  be  still  persistent  or  if 
active  symptoms  of  the  disease  continue,  even  if  the  fluid  seems  free 
from  diplococci.  It  is  only  in  the  exceptional  case,  whose  symptoms 
yield  promptly  and  in  which  the  diplococci  have  disappeared  that  fewer 
doses  are  permissible. 

Normal  cerebro-spinal  fluid  reduces  Fehling's  solution.     In  cerebro- 


CEREBRO-SPINAL  MENINGITIS  569 

spinal  meningitis  this  reduction  does  not  occur.  With  an  amelioration 
of  the  condition  this  reduction  gradually  returns  and  excellent  observers 
have  come  to  look  upon  its  return  as  one  of  the  indications  for  discon- 
tinuing the  administrations  of  the  serum.  It  may  be  added  that  this 
loss  of  reduction  of  Fehl ing's  solution  occurs  in  some  of  the  other  acute 
inflammations  of  the  spinal  cord. 

Results.  The  results  are  seen  both  in  the  amelioration  of  symp- 
toms and  in  the  change  wrought  in  the  cerebro-spinal  fluid. 

In  the  latter  the  diplococci  free  in  the  fluid  disappear,  then  the  intra- 
cellular  organisms  undergo  change,  that  retard  or  prevent  their  growth 
on  ordinary  media,  interfere  with  their  staining  properties,  then  dis- 
integration and  autolysis  take  place  with  diasppearance  of  the  bacteria. 
The  cerebro-spinal  fluid,  itself,  becomes  clearer;  the  pus  cells  disappear, 
Fehling's  solution  is  again  reduced,  while  in  the  blood  the  leucocytosis 
makes  way  for  a  normal  count. 

The  general  symptoms  show  improvement  in  the  lessening  of  the 
nervous  manifestations,  such  as  delirium,  in  a  lowering  of  temperature 
and  better  circulation  and  respiration.  The  improvement  is  more  often 
gradual,  the  temperature  going  down  by  lysis,  but  a  large  per  cent,  of 
the  cases  show  a  true  crisis  in  the  fever  and  a  precipitate  improvement 
in  the  other  symptoms.  The  disease  is  shortened  by  the  use  of  the 
serum,  complications  are  less  frequent  and  serious  sequelae  are  lessened. 

Bad  Results.  A  disagreeable  rather  than  a  dangerous  result  is 
serum  sickness  which  occurs  much  as  after  diphtheria  antitoxin  is 
administered.  (See  Diphtheria,  Chap.  XVIII.) 

The  more  dangerous  accidents  enumerated  above,  including  collapse, 
have  been  attributed  to  anaphylaxis,  rapid  lysis  of  the  cocci,  the  effect 
of  the  preservative  trikresol  and  increased  intracranial  pressure.  Worth 
Hale's  studies  attributed  the  dangerous  results  to  the  trikresol  used  to 
preserve  the  serum  as  well  as  to  intracranial  pressure,  but  Flexner 
believes  the  accidents  in  the  use  of  serum  cannot  be  attributed  to  ana- 
phylaxis nor  to  the  preservatives  and  would  attribute  them  all  to  the 
increased  intracranial  pressure. 

Lumbar  Puncture.  This  procedure  is  absolutely  essential  to 
the  diagnosis  and  to  the  serum  therapy  and  in  addition  affords  no 
small  measure  of  relief  from  certain  of  the  symptoms. 

It  is  an  exceedingly  simple  procedure  and  practically  free  from  danger, 
but  is  often  approached  by  him  who  undertakes  it  for  the  first  time  with 
trepidation  and  seems  to  the  parent  who  witnesses  it  an  heroic  under- 
taking, both  of  which  facts  make  for  delay  in  this  urgent  measure. 

Site.  The  site  of  puncture  is  determined  by  a  line  drawn  across 
the  spine  at  a  level  with  the  highest  points  of  the  crests  of  the  ilia;  a  tape 


570  TREATMENT  OF  ACUTE  INFECTIOUS  DISEASES 

or  a  string  stretched  between  these  points  gives  the  point  on  the  spine. 
The  spine  of  the  vertebra  nearest  this  point  is  the  fourth.  The  point 
of  insertion  of  the  needle  is  between  it  and  the  vertebra  above,  that  is, 
between  the  third  and  fourth  or  between  it  and  the  vertebra  below, 
that  is,  between  the  fourth  and  fifth. 

In  children  choose  the  exact  mid-line;  in  adults  choose  a  point  3/8 
to  3/2  inch  to  the  right  or  left  of  the  mid-line,  directing  the  point  of  the 
needle  inward,  i.  e.,  towards  the  mid-line,  going  in  between  the  laminae. 
This  rule  is  often  violated,  the  mid-line  being  chosen,  but  the  likelihood 
of  breaking  off  the  needle  and  danger  of  not  getting  into  the  canal  is 
enhanced  by  so  doing. 

Position  of  the  Patient.  The  patient  should  lie  on  his  side  at 
the  edge  of  the  bed  or  table  with  his  back  towards  the  operator.  An 
assistant  then  bends  the  child  forward,  by  gently  pressing  the  head 
down  and  the  knees  up  so  that  the  spine  curves  boldly  outwards,  thus 
separating  the  spines  of  the  vertebrae  from  each  other  and  making  the 
puncture  easier.  This  position  is  preferable  to  the  sitting  posture 
chosen  by  some  operators. 

Preparation  of  the  Patient.  The  skin  all  about  the  site  of  punc- 
ture should  be  cleansed  with  soap  and  water  and  then  with  alcohol, 
or  one  may  paint  the  site  of  puncture  with  tincture  of  iodine  after  a 
preliminary  cleaning  with  alcohol. 

Preparation  of  the  Operator.  The  hands  should  be  cleansed  with 
the  same  precautions  as  for  a  more  considerable  operation;  thoroughly 
with  soap  and  water,  followed  by  alcohol  or  one  may  use  sterile  gloves. 

Preparation  of  the  Apparatus.  All  the  apparatus  used  should  be 
rendered  sterile  by  boiling.  Appropriate  needles  or  trochars  and  canulas, 
a  syringe  and  test-tubes  constitute  the  paraphernalia. 

Anaesthetic.  It  is  better  to  do  without  an  anaesthetic.  The  pain 
is  but  slight,  as  patients  have  testified,  and  the  use  of  an  anaesthetic 
complicates  the  procedure.  If  an  older  child  or  adult  is  fearful  of  pain 
or  the  parents  insist,  a  local  anaesthetic  in  the  shape  of  ethyl  chloride 
to  freeze  the  site  of  puncture,  or  cocainization  with  1  per  cent,  to  2  per 
cent,  cocaine  is  to  be  preferred  to  general  anaesthesia;  if  this  may  not 
be  employed,  a  few  whiffs  of  chloroform  may  be  given.  Deep  anaesthesia 
is  entirely  unnecessary  and  adds  discomforts  and  dangers. 

Needle.  One  may  use  a  needle  or  a  trochar  and  canula.  The 
needle  should  be  stiff  of  a  fairly  good  calibre.  The  exploratory  needles 
used  for  paracentesis  of  the  thorax  or  other  cavity  or  antitoxin  needles, 
the  bore  and  length  depending  on  the  age  of  the  patient,  may  be  used, 
or  a  trochar  and  canula  or  a  special  lumbar  puncture  needle,  after  the 
pattern  of  Quincke. 


CEREBRO-SPINAL  MENINGITIS  571 

Needles  are  now  supplied  that  bend  but  do  not  break,  which  avoids 
an  embarrassing  accident. 

Needles  of  large  calibre  leave  a  wound  from  which  the  fluid  continues 
to  leak  and  increases  the  danger  of  infection.  I  have  found  the  explor- 
atory needles  more  satisfactory  than  trochar  and  canula. 

The  Tap.  When  the  point  of  entrance  has  been  determined,  it 
is  well  to  use  the  thumb  of  the  left  hand,  with  the  edge  of  the  nail  on 
the  upper  border  of  the  lower  vertebra  bounding  the  space  as  a  guide 
and  push  the  needle  along  the  back  of  the  nail  firmly  and  slowly  until 
a  lessened  resistance  tells  of  entrance  into  the  space,  of  which  the  flow 
of  fluid  is  corroborative,  when  the  open  end  of  the  needle  is  released 
or  the  trochar  is  withdrawn.  Care  should  be  taken  not  to  rudely  push 
the  needle  across  the  cerebro-spinal  cavity  against  the  body  of  the 
vertebra  as  bleeding  ensues  and  interferes  with  an  examination  of  the 
fluid. 

The  depth  to  which  the  needle  is  carried  is  in  children  about  an  inch. 
In  adults  it  is  considerably  more  and  the  needle  should  be  at  least  4 
inches  long. 

The  flow  may  be  drop  by  drop,  but  is  usually  continuous  or 
may  spurt  in  a  stream,  depending  on  the  pressure  and  the  bore  of  the 
needle. 

The  amount  varies  from  a  few  c.c.  to  50  or  60  c.c.  or  more. 
Twenty  to  30  c.c.  are  common  figures.  (Normal  infants  10  to  20;  older 
children  15  to  25.  Pfaundler.) 

Collecting  the  Fluid.  One  should  have  test-tubes  15  to  20  c.c. 
at  hand,  sterile  or  rendered  sterile  by  boiling  with  the  needles  and  syr- 
inge. The  open  end  of  the  tube  is  put  under  the  flow  and  filled  three- 
quarters  full,  leaving  room  to  introduce  a  sterile  cotton  plug  without 
touching  the  fluid.  If  the  fluid  runs  a  little  bloody  at  first  this  tube  as 
soon  as  the  fluid  runs  clear,  makes  way  for  another  tube  to  catch  the 
clearer  fluid.  Let  all  run  that  will,  catching  in  several  tubes. 

Sophian  takes  the  blood  pressure  during  the  tapping  and  if  it  falls. 
10  mm.  Hg.  he  discontinues  the  flow. 

After  plugging  the  tubes  they  should  be  set  upright  and  left  undis- 
turbed until  examined. 

Appearance  of  the  Fluid.  The  fluid' should  be  purulent  or  turbidr 
but  the  rule  is  not  invariable.  When  the  case  is  one  of  meningitis 
clinically,  a  fluid  which  is  purulent  or  turbid  indicates  serum  at  once 
without  awaiting  the  examination  of  the  fluid.  Again  if  the  fluid  is 
bloody  and  obscures  the  appearance  of  the  fluid  the  serum  should  be 
given. 

Only  in  case  the  fluid  is  watery  clear  should  one  await  for  the  results 


572  TREATMENT  OF  ACUTE  INFECTIOUS  DISEASES 

of  an  examination,  for  in  this  case  it  is  in  all  probability  a  case  of  tuber- 
cular meningitis,  serous  meningitis  or  poliomyelitis. 

In  other  words  always  give  the  patient  the  benefit  of  every  doubt 
in  giving  him  the  serum,  for  it  is  in  itself  harmless. 

Injection.  The  injection  should  be  by  the  gravity  method.  It  should 
be  made  very  slowly.  The  container  is  filled  with  serum,  which  should 
be  warmed  to  about  the  temperature  of  the  blood,  the  air  expelled,  and 
then  connected  with  the  needle;  the  patient  watched  carefully  for 
evidences  of  collapse,  poor  pulse,  cyanosis,  embarrassed  breathing,  upon 
the  appearance  of  which  some  of  the  serum  should  be  allowed  to  flow 
back  into  the  apparatus  until  improvement  occurs.  It  is  a  wise  precau- 
tion to  wait  a  few  minutes  after  the  injection  of  the  serum  before  the 
needle  is  withdrawn  so  as  to  make  unnecessary  another  puncture  if  signs 
should  develop.  After  the  needle  is  withdrawn,  remove  the  iodine  from 
the  skin  with  alcohol,  apply  sterile  gauze  to  the  puncture,  affixing  it 
by  adhesive  strips. 

Some  clinicians  deem  they  facilitate  the  diffusion  of  the  serum  in 
the  cord  by  raising  the  foot  of  the  bed. 

Special  gravity  apparatus  is  on  the  market  or  one  may  use  the  barrel 
of  a  15-25  c.c.  syringe  as  a  funnel,  to  which  is  attached  a  12-14  inch  long 
rubber  tube  about  1/4  inch  in  diameter  with  metal  end  piece  to  fit  end 
of  needle  (Sophian). 

This  method  has  replaced  the  older  syringe  method,  as  it  is  difficult 
to  produce  a  trauma  of  the  cord  by  it  as  the  inflow  is  more  even  and 
slower  and  if  bad  symptoms  arise,  the  fluid  can  be  drawn  off  by  simply 
lowering  the  container. 

If  breathing  is  bad,  artificial  respiration  may  be  instituted. 

Atropin  sulphate  in  doses  gr.  1/80  to  gr.  1/50  (0.00075-0.0012  Gm.) 
and  cocaine  hydrochloride  gr.  1/8  to  gr.  1/4  (0.008-0.015  Gm.)  is  ad- 
vised (Sophian). 

Reaction.  Headache  or  pain  in  the  back  and  limbs  may  ensue 
or  on  the  other  hand  the  patient  may  be  rendered  more  quiet,  but  as 
a  rule  no  bad  reaction  follows. 

Headache  may  be  relieved  sometimes  by  raising  the  pillow.  If  it  is 
very  severe  morphine  may  be  used. 

Dry  Tap.  Dry  taps  are  usually  due  to  failure  in  technique. 
For  this  reason  all  preparations  for  puncture  should  be  carried  out 
with  precision;  the  patient  held  firmly  in  the  position  desired,  the  land- 
marks carefully  determined  and  the  thrust  made  firmly  with  constant 
regard  to  the  direction.  With  repeated  punctures  the  patient  becomes 
more  alarmed  and  the  whole  procedure  made  more  difficult.  It  means 
in  the  great  majority  of  cases  that  the  canal  was  not  entered.  If  one 


CEREBRO-SPINAL  MENINGITIS  573 

feels  sure  that  he  has  entered  the  space  and  no  fluid  is  obtained,  he  may 
introduce  a  sterile  wire  through  the  needle  to  clear  it  from  a  plug  of 
tissue  that  may  be  occluding  it  and  if  not  successful  in  this  manoeuvre, 
withdraw  the  needle  and  go  in  a  space  above  or  below. 

The  dry  tap  may  be  due  to  inspissation  of  the  fluid.  Raising  the 
patient  to  a  sitting  position  may  initiate  the  flow ;  gentle  suction  of  the 
syringe  may  be  tried  or  a  little  salt  solution  or  a  little  serum  may  be 
gently  forced  in  or  the  use  of  two  needles  in  adjacent  spaces  with  saline 
irrigation  between  them  has  been  advised. 

In  true  dry  tap  one  may  force  much  smaller  amounts  in  at  more 
frequent  intervals.  No  great  pressure  should  be  used. 

In  this  city  the  serum  is  now  prepared  by  the  Board  of  Health 
(New  York). 

Tfc«  Possible  Bad  Results.  The  statement  made  that  the  proce- 
dure practically  entails  no  danger  it  is  thought  by  some  should  not  be 
taken  too  literally.  Wegeforth  and  Latham  contend  that  a  puncture 
should  not  be  lightly  undertaken  as  they  say  "The  two  cases  just  re- 
corded indicate  the  possibility  of  the  removal  of  cerebro -spinal  fluid 
acting  as  a  factor  facilitating  the  infection  of  the  meninges  from  the 
blood  stream."  They  contend  that  in  cases  of  septicemia  suspected  of 
being  meningococcic,  an  .examination  of  the  blood  should  be  made  to 
determine  the  nature  of  the  infecting  organism  and  if  the  invading 
organism  be  found  to  be  a  meningococcus  that  an  effort  should  first  be 
made  to  sterilize  the  blood  stream  by  the  use  of  the  antimeningococcic 
serum  before  the  cerebro-spinal  system  is  involved.  This  has  been  done 
on  several  occasions  and  by  different  workers.  They  would  delay  lumbar 
puncture,  then,  until  the  clinical  symptoms  of  invasion  of  cerebro-spinal 
system  is  sufficiently  definite  before  going  into  the  cord.  If  the  blood 
stream  shows  no  infection  at  all  the  risks  of  puncture  are  diminished. 
Even  then  they  advise  that  minimal  quantities  of  fluid  be  withdrawn  for 
laboratory  tests  with  small  bore  needles  so  that  the  pressure  relations 
within  the  cerebro-spinal  cavity  be  disturbed  as  little  as  possible. 

Another  unhappy  result  that  follows,  especially  on  too  frequent 
tappings,  comes  from  traumatism  done  by  the  needle  and  serum  to  the 
cord  and  meninges,  setting  up  a  myelitis  and  involvement  of  the  nerve 
roots,  which  affords  an  explanation  of  the  pain  and  stiffness  of  the  back 
and  legs,  so  often  felt,  atrophy  of  certain  muscles  and  vasomotor  dis- 
turbance. 

Early  Usage.  There  is  no  one  fact  more  emphasized  by  statis- 
tics than  that  every  hour  of  delay  in  the  usage  of  the  serum  adds  an 
appreciable  percentage  to  the  mortality.  Flexner  and  Jobling,  ana- 
lyzing over  350  cases,  show  that  when  the  serum  was  administered 


574  TREATMENT  OF  ACUTE  INFECTIOUS  DISEASES 

on  the  first  to  4he  third  day,  in  123  cases  the  mortality  was  16.5  per 
cent.,  on  the  fourth  to  the  seventh  day  in  126  cases  the  mortality  was 
23.8  per  cent.,  and  later  than  the  seventh  day  of  112  cases  the  mortality 
was  35  per  cent. 

Intravenous  Treatment.  The  intensive  study  of  cases  in  camps 
during  the  late  war  has  made  it  more  and  more  probable  that  the  disease 
instead  of  localizing  itself  in  the  brain  and  cord  primarily  is  a  septicemia 
in  the  beginning,  localizing  itself  secondarily  in  the  cerebro-spinal 
system.  Herrick  was  able  to  get  positive  blood  cultures  in  about  1/3  of 
his  cases  and  claims  that  when  the  best  laboratory  technique  is  available 
these  figures  rise  to  50  per  cent,  and  even  to  80  per  cent. 

In  45  per  cent,  of  his  cases  he  was  able  to  recognize  the  infection 
before  the  meningitis  occurred  and  this  stage  of  premeningitic  general- 
ized infection  he  found  to  vary  between  a  few  hours  and  several  daj^s,  the 
average  48  hours. 

The  diagnosis  of  these  early  cases  is,  of  course,  materially  aided  by 
the  presence  of  an  epidemic.  The  patient  looks  and  feels  ill,  not  infre- 
quently there  is  an  early  tonsillitis  or  laryngitis  of  varying  degrees  of 
severity;  there  is  a  moderate  fever  and  the  patient  complains  of  a  severe 
headache;  this,  however,  is  not  constant.  More  significant  is  the  apathy 
and  emotionless  expression  of  the  patient.  The  conjunctivas  are  red- 
dened, often  strikingly  inflamed,  and  the  organism  may  be  recovered 
from  the  secretions.  Of  diagnostic  significance  is  the  petechial  rash, 
coming  out  rapidly  in  crops.  This  is  seen  on  the  trunk  and  less  con- 
stantly on  the  extremities,  face,  conjunctivas  and  in  the  mucous  mem- 
brane of  the  mouth.  These  may  be  few  and  discrete  and  give  the  ap- 
pearance of  an  extensive  purpura. 

There  may  be  at  this  early  stage  of  the  infection  none  of  the  signs  of 
brain  and  cord  involvement  other  than  may  be  attributed  to  any  severe 
infection  and  some  inequality  and  irregularity  of  reflexes  and  the  spinal 
cord  fluid  shows  no  more  than  one  finds  in  other  acute  infections.  Blood 
cultures  yield  the  specific  organisms  in  the  proportions  cited.  Herrick's 
plea  for  the  prompt  and  efficient  use  of  the  serum  by  the  intravenous 
route  is  logical  and  the  following  is  largely  abstracted  from  his  article 
in  the  Journal  of  the  A.  M.  A.,  Vol.  71,  No  8,  Aug.  24th,  1918,  p.  612. 

The  patient  is  first  given  a  desensitizing  dose  of  1  c.c.  of  the  serum 
subcutaneously;  an  hour  later  an  intravenous  injection  of  antimenin- 
gococcus  serum  is  given.  As  a  further  precaution  to  avoid  anaphy lactic 
reactions  the  first  15  c.c.  are  given  very  slowly  at  the  rate  of  1  c.c.  a 
minute,  the  rest  more  rapidly.  The  dose  is  80  to  150  c.c.  serum,  depend- 
ing on  the  degree  of  toxicity,  but  the  larger  doses  are  always  the  safer. 

If  during  the  injection  any  untoward  symptoms  appear  the  injection 


CEREBRO-SPINAL  MENINGITIS  575 

is  immediately  intermitted.     These  symptoms  are  pallor  or  cyanosis, 
weak,  rapid  and  irregular  pulse  or  dyspnoea  or  vomiting. 

After  two  or  three  hours  it  is  perfectly  safe  to  make  another  effort 
and  success  rarely  fails.  Even  patients  sensitized  by  previous  serum 
may  be  so  handled.  Herrick  advises  atropine  and  morphine  before  the 
administration  or  at  any  rate  if  symptoms  cited  occur.  Epinephrin, 
too,  is  of  value.  (See  serum  treatment  of  Pneumonia,  Chap.  IX.) 

Frequency.  In  severe  cases  the  serum  should  be  repeated  every 
8  to  12  hours  throughout  the  acute  stage  of  2  to  4  days,  in  milder  cases 
every  24  hours. 

In  Herrick's  experience  the  average  number  of  injections  given  were 
between  4  and  5  and  the  total  serum  400  c.c.  He  gave  one  patient  12 
doses,  totalling  1050  c.c.  Success  may  in  a  measure  be  checked  up  by 
blood  cultures,  due  allowance  being  made  for  imperfections  of  technique. 
If  on  the  evidences  of  septicemia  a  puncture  of  the  spinal  cord  is  made, 
which  is  the  rule,  it  seems  to  me  that  a  small  needle  should  be  used  and 
only  such  amounts  withdrawn  as  will  establish  diagnosis. 

Wegeforth  and  Latham  would  have  us  puncture  the  cord  only  when 
signs  of  meningitis  have  developed  and  after  intravenous  injections 
of  serum. 

Herrick  puncturing  early  and  finding  clear  fluid  lets  the  cord  alone; 
when  signs  of  meningitis  occur  he  would  withdraw  only  enough  fluid 
from  the  canal  to  lessen  its  pressure  to  normal  and  that  only  about  a 
half  hour  after  intravenous  injection  (italics  mine)  and  then  introduce 
not  more  than  30  c.c.  into  the  cord.  After  this  he  would  drain  the  cord 
freely  on  the  occasion  of  further  intraspinal  therapy,  utilizing  the 
effects  of  such  drainage  on  the  choroid  plexus  to  increase  the  perme- 
ability to  the  antibodies  in  the  blood  stream. 

His  average  intraspinal  injections  numbered  four.  The  efficacy  of 
the  intravenous  treatment  undoubtedly  lessens  the  number  of  spinal 
injections  needed.  If  8  or  10  intraspinal  injections  are  not  efficacious, 
it  is  wise  to  interrupt  the  treatment,  draining  only  so  often  as  to  relieve 
pressure  symptoms.  Some  men  (Olitsky)  believe  drainage  quite  as 
effectual  as  serum.  The  lack  of  success  in  any  given  case  may  be  due 
to  the  serum.  It  is  well,  then,  when  meningococci  are  recovered  by 
culture  to  determine  by  them  the  agglutization  power  of  the  serum  used. 
Even  when  this  cannot  be  done,  it  is  well  to  try  a  serum  from  another 
source  as  possibly  derived  from  similar  strains. 

Fulminating  Cases.  The  overwhelming  rapidity  of  these  cases 
does  not  permit  of  timely  intervention  on  the  part  of  the  physician. 
The  patients  are  profoundly  affected  when  seen.  These  are  cases  in 
which  intravenous  injections  as  advised  are  urgent. 


576  TREATMENT  OF  ACUTE  INFECTIOUS  DISEASES 

With  meningeal  involvement  more  frequent,  dosage  by  the  spinal 
route,  as  Dunn  urges,  seems  rational.  He  advises  a  dose  at  once  and 
another  as  soon  as  the  beneficial  effects  begin  to  wane,  which  may  be 
in  a  few  hours,  or  to  give  the  dose  at  twelve-hour  intervals. 

The  best  result  I  have  ever  obtained  was  after  intraspinal  injections 
of  6  to  8  hour  intervals,  gradually  lengthened  as  improvement  followed. 
This  was  before  intravenous  treatment  was  urged.  The  frequent 
drainage  of  pus  may  have  contributed  materially  to  the  fortunate 
issue. 

Chronic  Cases.  In  the  prolonged  cases,  as  long  as  there  are 
diplococci  in  the  fluid  or  fever  or  pain  or  symptoms  of  activity  of  the 
process  in  any  terms,  except  a  rigidity  of  the  neck  and  Kernig's  sign, 
which  are  apt  to  persist  for  some  time  after  complete  disappearance 
of  other  symptoms,  the  treatment  should  be  continued.  Dunn  has 
advised  as  a  routine  that  after  four  doses  on  consecutive  days,  a  wait 
of  a  few  days  follow  and  then  again  a  course  of  four  treatments  be  given 
and  again  a  wait  and  so  on  until  all  signs  disappear. 

It  would  seem  advisable  to  change  the  serum  used  in  the  cases  or 
to  try  the  effects  of  drainage  alone  for  a  time. 

Sophian  has  used  in  the  chronic  cases  meningococcic  vaccine  as  an 
adjuvant  to  the  serum  treatment.  The  doses  are  50,000,000,  up  to 
1,000,000,000  or  1,500,000,000  every  three  to  five  days. 

Hydrocephalus  in  the  chronic  cases  demands  taps  at  daily  in- 
tervals or  once  in  two,  three,  or  four  days,  depending  on  symptoms. 

Relapses.  Relapses  occur  in  a  small  per  cent,  of  the  cases, 
though  Ker  found  that  15  to  20  per  cent,  of  his  cases  relapsed. 

A  relapse  is  to  be  treated  like  a  fresh  case,  in  all  the  details  specified. 

Exacerbations  in  the  course  of  a  case  are  to  be  treated  in  the  same 
vigorous  manner. 

When  the  spinal  fluid  is  too  thick  to  run  through  the  needle,  it  has 
been  advised  to  use  a  sterile  physiological  salt  solution  to  irrigate  the 
cord  and  then  inject  the  serum. 

When  for  other  reasons  the  tap  is  dry  and  particularly  in  infants 
a  puncture  into  the  ventricles  has  been  made,  the  cerebro-spinal  fluid 
withdrawn  and  the  serum  given  into  the  ventricles. 

Puncture  of  the  Ventricles.  In  posterior  basal  meningitis,  the 
use  of  serum  by  the  intradural  method  is  hazardous  and  useless.  The 
hydrocephalus  demands  puncture  of  the  ventricles  daily  or  less  often 
according  to  the  severity  of  symptoms. 

If  the  fluid  is  infected,  serum  is  injected  into  the  ventricles  as  into  the 
cord. 

This  procedure  is  not  difficult  in  infants.     The  anterior-fontanelle 


CEREBRO-SPINAL  MENINGITIS  577 

is  used.  One  enters  at  the  lateral  border,  pushes  the  needle  down, 
back  and  in  to  the  depth  of  2  to  4  cm. 

Use  the  same  needle  as  in  lumbar  puncture. 

In  older  individuals  the  puncture  must  follow  a  trephining. 

Results.  The  mortality  in  different  epidemics  in  different  local- 
ities showed  about  75  per  cent.  The  analysis  of  the  first  400  cases 
after  the  introduction  and  use  of  the  antitoxin  reversed  the  figures; 
75  per  cent,  recovered  and  25  per  cent.  died. 

Of  infants  under  one  year,  before  the  introduction  of  antitoxin  the 
mortality  was  approximately  100  per  cent.;  a  recovery  a  rarity.  After 
the  introduction  of  antitoxin,  of  the  first  twenty-two  treated  50  per 
cent,  recovered. 

In  1914  Flexner  reported  on  1,294  cases  treated  with  his  serum. 
The  mortality  was  31  per  cent. 

For  those  treated  on  the  first  to  the  third  day  the  mortality  was  18 
per  cent.,  on  the  fourth  to  the  seventh  day  27  per  cent.  Later  than 
the  seventh  day  36.5  per  cent. 

The  highest  mortality  was  under  one  year,  49.6  per  cent.;  the  lowest 
from  five  to  ten  years,  15.1  per  cent. 

Thirty  per  cent,  of  the  cases  reported  by  Flexner  ended  by  crises. 

In  a  few  cases,  he  says,  the  meningococci  seem  to  be  serum  fast ;  and 
in  a  number  of  relapses  the  cocci  seem  to  have  acquired  serum  fastness 
and  defeat  the  effort  of  the  serum. 

Complications.  Changes  in  mentality,  varying  from  irritability 
and  changes  in  disposition  to  profound  damage  together  with  different 
paralyses  may  ensue. 

Relief  of  intracranial  pressure  must  be  afforded  by  frequent  tappings, 
by  the  use  of  the  vaccine  and  serum. 

Eye  complications  are  varied  in  type,  in  part  due  to  effects  on  cen- 
tres from  pressure  or  meningo-en cephalitis  and  to  be  treated  by  tap- 
ping and  the  use  of  serum  and  vaccines;  and  in  part  local,  such  as 
severe  conjunctivitis  or  even  suppurative  processes,  panopthalmitis 
with  blindness. 

These  are  to  be  treated  as  under  other  circumstances,  but  the  use 
of  the  serum  locally  may  help  materially.  The  ocular  muscles  may  be 
involved. 

Ear.  Otitis  is  very  common,  occurring  in  over  10  per  cent,  of  the 
cases  and  is  to  be  treated  by  paracentesis. 

For  treatment  of  Otitis  Media  see  Scarlet  Fever,  Chap.  XVII. 

Deafness  is  another  unfortunate  issue. 

Joints.  An  involvement  of  the  joints  takes  place  in  15  per  cent, 
of  the  cases  and  may  be  a  polyarthritis,  lasting  weeks  or  months. 


578  TREATMENT  OF  ACUTE  INFECTIOUS  DISEASES 

Vaccines  (see  text)  are  indicated. 

Fluid  may  be  removed  from  a  joint  and  serum  injected  (e.  g.,  10- 
15  c.c.  into  knee)  with  great  benefit. 

Pains  may  be  relieved  by  the  use  of  salicylates  or  local  measures. 
(See  Rheumatism,  Chap.  III.) 

During  the  acute  stages  pneumonia  is  fairly  common,  pleurisy,  peri- 
tonitis, pericarditis,  endocarditis  less  so.  With  intravenous  treatment 
the  complications  are  less  frequent.  For  measures  directed  at  relief  of 
symptoms  and  support  of  circulation,  see  Pneumonia  and  Rheumatism, 
Chaps.  IX  and  III.) 

Pyelitis  is  fairly  common. 

Meningococci  may  be  found  in  the  urine  even  before  they  are  deter- 
mined in  the  cerebro-spinal  fluid. 

Urotropin  should  be  used.    (See  Typhoid  Fever,  Chap.  XIV.) 

In  severe  cases,  subcutaneous  or  intravenous  use  of  serum  and  the 
use  of  vaccines  would  be  indicated. 

Convalescence.  This  period  varies  greatly.  It  may  be  fairly 
prompt,  long  delayed  from  weakness  and  poor  nutrition  or  complicated 
with  permanent  damage  to  some  centres  in  brain  or  cord  or  with  some 
of  the  conditions  mentioned. 

Air,  sunlight,  an  abundance  of  good  food  and  good  nursing  are  the 
main  indications. 

It  has  been  advised  (Herrick)  to  use  vaccine  during  convalescence  to 
prevent  recurrences,  e.  g.,  3  to  5  injections  at  6-day  intervals  of  50  to 
200  millions  of  killed  autogenous  meningococci;  for  some  prolonged 
convalescences  or  recurrences  would  seem  to  be  due  to  organisms  pro- 
tected by  exudates  undergoing  mucoid  transformations  or  perhaps 
derived  from  nose,  accessory  sinuses,  eye,  ear  or  pericardium.  This 
would  seem  to  be  a  wise  measure. 

Orchitis  and  epididymitis  are  other  rare  complications.  For  local 
treatment  see  Mumps  (Chap.  XXIII). 

Prophylaxis.     Protection  of  the  individual. 

Serum  may  be  used  subcutaneously,  just  as  diphtheria  antitoxin, 
to  afford  passive  immunity  and  it  has  been  claimed  that  it  affords  such 
immunity  over  a  period  of  two  to  three  weeks. 

It  would  be  indicated  for  those  who  find  themselves  in  immediate 
contact  with  a  patient;  doctors,  nurses,  and  members  of  the  patient's 
family. 

What  is  believed  to  afford  a  more  lasting  and  effectual  protection  is 
afforded  by  vaccines. 

These  vaccines  have  been  given  in  the  same  doses  and  at  the  same 
intervals  (weekly)  as  the  antityphoid  vaccine;  namely,  500,000,000- 


CEREBRO-SPINAL  MENINGITIS  579 

1,000,000,000;  but  Sophian,  because  of  the  rather  striking  pain  in  the 
neck,  which  alarmingly  suggests  the  real  disease,  after  the  initial  injec- 
tion, recommends  as  a  first  dose,  100,000,000,  followed  in  a  week  by 
500,000,000  and  in  another  week  by  1,000,000,000. 

Carriers.  Fifty  per  cent,  and  in  some  epidemics  even  a  much 
higher  per  cent,  of  contacts  become  carriers,  and  infection  through  the 
third  person  is  common ;  95  per  cent,  of  these  carriers  do  not  suffer  them- 
selves. 

All  contacts  should  be  examined  and  those  found  to  be  " carriers" 
should  be  quarantined  until  their  nasal  discharges  are  negative  for 
the  meningococci  on  two  occasions,  and  Sophian  advises  that  those 
contacts  be  quarantined  a  week  even  when  the  discharges  are  negative. 

As  the  incubation  period  is  nearly  two  weeks  it  would  seem  wise 
to  quarantine  for  this  period. 

As  Major  Russell  has  remarked,  it  is  the  chronic  carrier  with  large 
number  of  meningococci  always  present  that  constitutes  the  real  danger 
rather  than  a  man  with  a  few  organisms.  He  must  be  kept  under  ob- 
servation. 

In  quarantine  they  should  use  the  mild  antiseptic  sprays,  such  as 
2  per  cent,  boric  acid  solution  or  quarter  strength  Dobell's  solution. 

Sophian  lays  great  stress  on  the  use  of  saline  douches  three  times 
a  day,  followed  by  a  spray  of  peroxide  of  hydrogen  1/2-1  per  cent. 

Others  recommend  the  blander  silver  preparations,  but  astringents 
that  irritate  the  mucous  membrane  and  so  lower  its  resistance  should 
never  be  used. 

SUMMARY 

Distribution  of  the  family. 

The  disease  is  contagious  and  isolation  should  be  obligatory. 

The  children  of  the  family  and  other  "contacts"  should  be  kept 

from  other  children,  as  possible  carriers. 
The  children  of  the  family  should  be  isolated  over  a  period  that 

probably  covers  the  illy  defined  incubation  period,  i.  e.,  three  to 

four  weeks. 

The  nasal  passages  of  the  suspects  should  be  examined  for  diplococci. 
Adults,  too,  should  be  kept  from  the  sick-room  unless  their  duty 

keeps  them  there. 
Adults  of  the  family  should  not  come  in  contact  with  other  children 

and  if  their  duty  brings  them  in  contact  with  children,  they  should 

remove  from  the  environment  of  the  patient  and  submit  to  the 

isolation  period  before  seeing  children  again. 
Contacts  should  have  their  nasal  secretions  examined.    If  they  are 

positive,  they  should  keep  from  children  during  the  epidemic  and 

if  possible,  isolate  themselves  until  the  cultures  are  negative. 


580  TREATMENT  OF  ACUTE  INFECTIOUS  DISEASES 

Avoid  infections  of  nasal  passages,  especially  during  epidemics  of 

colds  and  sore  throats. 
" Contacts"  should  use  a  mild  spray  for  the  throat  and  nose,  2  per 

cent,  boric  acid  solution  or  quarter  strength  DobelFs  Solution 
Never  use  strong  astringents. 

Nurse. 

Some  cases  a  night  and  day  nurse. 
Very  likely  to  become  a  "  carrier." 
Avoid  contact  with  children. 

Remember  the  ease  of  conveyance  by  kissing,  coughing  and  sneezing. 
Before  going  out  clea'n  hands  and  face  with  soap  and  water  followed 

by  alcohol  or  1-1,000  bichloride  and 
Spray  throat  and  nose  with  the  mild  solutions  mentioned. 
Should  spray  throat  and  nose  from  time  to  time  while  on  duty. 

Physician. 

Should  make  his  visits  as  short  as  is  compatible  with  his  full  duty. 
On  leaving,  wash  face  and  hands  with  soap  and  water  followed  by 

alcohol  or  bichloride  1-1,000. 
He  should  not  see  another  child  at  once. 

Room. 

Choose  with  reference  to  light. 

Air. 

Verandah  or  porch  approach. 

Bath  room  near  by. 

Should  be  stripped  of  furnishings. 

Carpet  lining  or  unbleached  muslin  on  the  floor. 

Screens  for  the  eyes,  if  sensitive  to  the  light. 

Avoid  jars,  noise  and  other  sources  of  irritation. 

Precautions  in  the  sick-room. 

Nasal  and  oral  secretions  should  be  received  on  rags  and  burned  or 

disinfected  in  1-20  phenol  or  1-500  bichloride. 
Thermometer. 

Should  be  left  in  sick-room  and  kept  in  2  per  cent,  phenol  or  in 

formalin. 
Eating  utensils. 

Boil  in  sick-room,  or  if  sent  out  of  sick-room  soak  in  phenol  1-20 
for  twenty  minutes  to  half-hour,  then  send  out  to  be  boiled. 
Clothes. 
Soak  overnight  in  1-20  or  1-50  phenol,  then  boil  half-hour  before 

sending  to  the  family  wash  or  laundry. 
Urinals,  bed-pans,  etc. 

1-20  carbolic  or  1-500  bichloride. 

Bed. 

(For  technique  of  bed  making,  see  Pneumonia,  Chap.  IX.) 
Especial  care  should  be  taken  on  account  of  bed-sores. 


CEREBRO-SPINAL  MENINGITIS  581 

With  any  threat  of  bed-sores 
Air  mattresses  or 
Water-bed. 

Clothing  somewhat  more  abundant  than  usual  on  account  of  ex- 
treme sensitiveness  to  cold. 

Patient. 
Isolation. 

Nightgown  should  be  of  light  flannel  or,  if  irritating,  cotton. 
Should  be  open  all  the  way  down  the  front  to  facilitate  exami- 
nations. 

Diet. 

Early  days  do  not  force. 

Later  consider  the  body  needs. 

Articles  of  diet.    (See  text.) 

In  infancy  modified  milk  is  to  be  further  diluted. 

In  stupor  or  dysphagia. 

Nasal  or  oral  gavage. 

Nasal  better  in  children;  oral  in  infancy. 
Drinks  should  be  forced. 

Water,  alkaline  waters,  fruit  juice,  as  lemonade,  etc. 

Care  of  body. 

Skin. 

Cleansing  bath  of  soap  and  water  daily. 
Bed-sores. 

Prevention.    Change  of  position. 

Scrupulous  dryness;  use  of  rings  and  cushions. 

Rubbing  of  skin  with  hands. 

Use  of  alcohol  and  talcum  powder. 

Care  of  bed  in  avoidance  of  wrinkles  and  crumbs  of  food. 

When  sores  threaten,  use  air  mattresses  or  water-beds. 

Sores  should  be  handled  on  surgical  principles. 
Mouth  and  nose. 

Remember  that  the  secretions  are  infectious. 

Rinse  mouth  with  plain  water,  then  with 

Boric  acid  solution  2  per  cent,  to  4  per  cent,  or  with 

Dobell's  solution  quarter  to  half  strength. 
Teeth. 

Brushed  with  soft  brush  or  cotton  swabs,  wet  with  above  solu- 
tions, care  being  taken  to  free  interstices  from  particles  of  food. 

Remove  particles  between  gums  and  cheeks. 
Sordes  and  coated  tongue. 

Soften  with  half  strength  official  peroxide  of  hydrogen,  then  scrape 
tongue  with  edge  of  whalebone. 

Follow  with  the  boric  acid  or  Dobell's  solution. 
Dry  mouth  and  tongue. 

Use  2  percent,  boric  acid  solution. 

Albolene  aa. 

Flavor  with  lemon-juice. 


5S2  TREATMENT  OF  ACUTE  INFECTIOUS  DISEASES 

Nose. 

Soften  hard  secretions  with  olive  oil. 

Spray  with  boric  acid  or  Dobell's  solutions. 

Burn  all  secretions  as  infectious. 

Nurse  should  carefully  wash  hands  and  use  alcohol  or  1-1,000 

bichloride  as  an  antiseptic  after  these  ministrations. 
Eyes. 

Mild  conjunctivitis  is  common. 

Secretions  are  probably  infectious  and  should  be  burned. 

Cleanse  eyes  with  2  per  cent,  boric  acid  solution. 

Care  of  bowels. 
Open  freely  at  the  beginning. 
Calomel,  gr.  1/4  (0.015  Gm.)  every  quarter  hour  for  four  or  five 

doses,  or  gr.  1/10  (0.006  Gm.)  every  ten  minutes  for  ten  doses. 

Follow  in  two  to  three  hours  by  milk  of  magnesia  gss.  (15  Gm.)  if 

there  is  vomiting, 

Castor  oil  3ii-iv  (8-15  Gm.)  if  there  is  no  vomiting;  or 
Sal  Rochelle  5ji-5ss.  (8-15  Gm.)  or 
Epsom  salt  3ii~5ss.  (8-15  Gm.)  in  half  to  three-quarter  glass  of 

water. 
Throughout  the  illness  use, 

Milk  of  magnesii  5iH5ss.  (8-15  Gm.)  or 

Liquor  magnesias  citratis  giv-viii  (120-240  Gm.), 

Hunyadi  or  similar  water. 
Enemata,  especially  if  there  is  vomiting,  though  hyperesthesia  may 

make  it  a  too  distressing  procedure. 

Nausea. 

A  feature  of  the  onset  is  vomiting,  and  it  may  continue  for  some 

time. 

One  may  try- 
Cracked  ice. 

Mustard  paste,  1  in  3,  4,  5,  or  6  of  flour  to  pit  of  stomach. 
(For  technique,  see  Pneumonia,  Chap.  IX),  or 

Sodium  Bicarbonate gr.  x-gr.  xv  (0.60-1  Gm.)  or 

Bismuth  Subnitrate gr.  x-gr.  xv  (0.60-1  Gm.)  or 

Cerium  Oxalate gr.  iii  to  gr.  v  (0.20-0.30  Gm.)  or 

a  combination  of  the  three. 
Lavage. 

Treatment  of  symptoms. 

Restlessness,  delirium,  sleeplessness. 

Ice-cap  or  ice-coil. 

Warm  sponge  baths. 

Bromides,  in  doses  gr.  x  to  gr.  xxx  (0.60-2  Gm.)  according  to  age. 

More  severe. 

Codeine  phosphate  in  doses  of  gr.  1/48-gr.  ss.  (0.0015-0.030  Gm.) 
according  to  age. 


CEREBRO-SPINAL  MENINGITIS  583 

Very  severe.    Morphine  sulphate  in  doses  of  gr.  1/48-gr.  1/4  (0.0015- 

0.015  Gm.). 

Hyoscine  hydrobromide  in  doses  of  gr.  1/300-gr.  1/100  (0.0002- 
0.0006  Gm.)  in  adults. 

Convulsions. 
Slight  twitchings. 

Chloral  best  given  by  the  rectum  in  warm  milk. 
Dose,  gr.  v  to  gr.  xxx  (0.30-2  Gm.)  according  to  age. 
Bromides  may  be  added  to  the  chloral  in  double  the  dose  of  the  latter, 

and  may  be  given  by  mouth  or  rectum. 
Severe  convulsions. 

Morphine  sulphate,  doses  of  gr.  1/24  to  gr.  1/3  (0.003-0.020  Gm.). 

For  details  of  treatment  of  convulsions  in  children,  see  index. 

Circulation. 

So  far  as  influenced  by  the  intracranial  pressure,  do  a  lumbar  punc- 
ture. 

For  continuous  support  use  digitalis  in 
doses  of  gr.  ss.  to  gr.  iii  (0.030-0.20  Gm.)  three  times  a  day  (3ss. 

to  5ss.  of  infusion  (2-8  c.c.).  or 
m.  v  to  m.  xxx  (0.30-2  c.c.)  of  the  tincture. 
Strophanthin  in  emergency  in 

doses  of  gr.  1/120  to  gr.  1/60  (0.0005-0.001  Gm.). 
For  immediate  demands. 
Caffeine  in 
doses  of  gr.  ss.  to  gr.  v  (0.0>30-0.30  Gm.)  every  two  hours  as  a 

soluble  salt  of  caffeine  sodium  salicylate  or  sodium  benzoate. 
Intravenous  injection  of  glucose.    (See  text.) 

Bladder. 

Watch  for  distension. 
Apply  hot  stupes  over  the  epigastrium. 
Catheterize. 
Urotropin. 
Doubtful  value. 
Dose,  gr.  v  (0.30)  two  to  four  times  a  day  well  diluted. 

Specific  treatment 
For  preparation  of  serum  and  the  theory  of  its  action,  see  text. 

Administration  of  serum. 

Intravenous  treatment.  As  the  infection  is  probably  in  the  beginning 
a  septicemia  intravenous  treatment  is  indicated. 

(For  discussion,  see  text.) 

Diagnosis  may  be  made  before  cerebro-spinal  symptoms  develop. 
(See  text.) 

Determine  sensitization  by  intradermal  method.  (See  Pneumonia. 
Chap.  IX.) 


584  TREATMENT  OF  ACUTE  INFECTIOUS  DISEASES 

If  this  cannot  be  done,  in  cases  of  known  sensitization  or  best  in  any 
case,  give  desensitizing  dose  of  1  c.c.  subcutaneously,  one  hour 
later  give  full  dose;  first  15  c.c.  at  rate  of  1  c.c.  per  minute.  Give 
rest  more  rapidly. 

Dose  150  c.c. 

If  untoward  symptoms  appear: — cyanosis,  pallor,  dyspnoea,  vomit- 
ing— cease  injection  for  one  hour  and  then  try  again.  Atropine 
sulphate  gr.  1/150-1/100  (0.0044-0.0066  Gm.)  or  morphine  sul- 
phate gr.  1/4-1/8  (0.015-0.008  Gm.).  Epinephrin  (adrenalin) 
1:1000  m.  xv  intravenously. 

Frequency. 

Eight  to  twelve  hours  in  severer  cases;  24  hours  in  less  severe  during 
the  acute  stage.  Usually  takes  4-5  doses. 

Mode  of  administration. 

(See  Pneumonia,  Chap.  IX.) 

Intraspinal  treatment. 

Unless  cerebro-spinal  symptoms  occur  it  is  best  not  to  puncture 
the  cord,  or  to  use  small  needle  and  withdraw  small  amounts. 
On  the  appearance  of  cerebro-spinal  symptoms  puncture  the  cord 
preferably  about  a  half  hour  after  an  intravenous  injection,  re- 
moving enough  to  relieve  pressure  and  introducing  not  more  than 
30  c.c.  of  serum  into  the  canal;  if  further  spinal  therapy  is  neces- 
sary, drain  cord  and  follow  procedure  below. 

Dosage. 

Only  limited  by  the  capacity  of  the  spinal  canal.  Rule,  30  c.c. 
or  if  more  than  this  amount  of  cerebro-spinal  fluid  is  with- 
drawn from  the  canal,  replace  an  equal  amount  of  serum. 

If  less  than  30  c.c.  of  cerebro-spinal  fluid  is  withdrawn,  approxi- 
mate the  dosage  of  serum  to  30  c.c.  but  without  forcing  against 
resistance. 

Sophian  is  guided  by  blood  pressure  readings.    (See  text.) 

For  Sophian's  table  of  dosage  at  different  ages,  see  text. 
Frequency  of  dosage. 

Once  a  day  for  three  or  four  days  or  longer  if  meningococci  per- 
sist in  the  cerebro-spinal  fluid  or  the  symptoms  are  active. 

Favorable  results  are  shown  by  amelioration  of  symptoms  and 

change  in  cerebro-spinal  fluid. 
(For  details,  see  text.) 

Lumbar  puncture. 

Site.    In  a  line  with  the  iliac  crests.    Crosses  spine  nearest  to  fourth 

lumbar. 
Go  in  between  fourth  and  third  lumbar  or  between  fourth  and  fifth 

lumbar. 
In  children  enter  needle  in  exact  mid-line  of  vertebral  column. 


CEREBRO-SPINAL  MENINGITIS  585 

In  adults  enter  3/8"-l/2"  to  right  or  left  of  mid-line  and  direct 
needle  inward  toward  the  middle  line.    The  mid-line,  however,  is 
preferred  by  many  operators. 
Position  of  the  patient. 

On  his  side  with  back  toward  the  edge  of  the  bed  or  table,  head  and 

knees  approximated. 
Preparation  of  patient. 

Wash  site  with  soap  and  water  and  alcohol  or 
Paint  the  site  with  tincture  of  iodine. 
Preparation  of  the  operator. 

Prepare  as  for  a  surgical  operation. 
Soap  and  water  and  alcohol  or  sterile  gloves. 
Preparation  of  the  apparatus. 
All  should  be  sterilized  by  boiling;  needles,  trochars  and  canulas, 

syringe  and  test  tubes. 
Anaesthetic. 

Better  none;  pain  is  trivial. 

If  fear  makes  it  advisable  freeze  site  with  ethyl  chloride  or  use 
1  per  cent,  to  2  per  cent,  cocaine  solution  or  give  a  whiff  of 
chloroform. 
Needle. 
Should  be  stiff  and  of  fairly  good  calibre,  such  as  is  used  for  thora- 

centesis  or  diphtheria  antitoxin  administration. 
Trochar  and  canula. 
Quincke  needle. 
The  Tap. 
Guide  needle  along  upper  thumb-nail  pressed  against  upper  border 

of  lower  vertebra  bounding  the  space  to  be  entered. 
Lessened  resistance  tells  of  entrance  of  needle  into  canal. 
Flow  through  needle  corroborates  entrance. 
Don't  push  needle  across  space  into  body  of  vertebra,  lest  bleeding 

ensue  and  spoil  fluid  for  examination. 
Depth  of  entrance. 

In  children  about  1",  in  adults  more. 
Needle  should  be  4"  long  at  least. 
The  flow. 

May  be  drop  by  drop;  but  is  usually  continuous  or  in  a  spurt. 
The  amount. 

Normal  infants,  10  to  20  c.c. 
Older  children,  15  to  25  c.c. 
Adults,  20  to  30  c.c. 

May  vary  in  meningitis  from  a  few  c.c.  to  50-60-100  c.c. 
Collecting  fluid. 
-Sterile  test-tubes  15  to  20  c.c. 
Fill  not  more  than  three-quarters,  so  that  plug  of  cotton  will  not 

touch. 
If  fluid  runs  bloody,  catch  this  in  one  tube  and  the  clearer  in  the 

other. 
Let  all  flow  that  will,  or 


586  TREATMENT  OF  ACUTE  INFECTIOUS  DISEASES 

If  blood  pressure  falls  10  mm.  during  the  tapping  it  is  well  to 

discontinue.    (Sophian). 
Plug  and  set  upright. 
Appearance  of  fluid. 

Usually  turbid  or  purulent. 

Don't  wait  for  examination,  but  give  the  serum. 

If  blood  obscures  it,  don't  wait,  give  serum. 

If  watery  clear,  wait  and  examine.    May  be  tuberculous  or  serous 

meningitis  or  poliomyelitis. 

Give  patient  benefit  of  any  doubt  by  administering  the  serum. 
The  injection. 

Fill  the  container  with  serum  warmed  to  blood  heat;  expel  all  air. 
Inject  slowly  by  gravity  method. 
,.  • .  Some  advise  raising  foot  of  the  bed  to  facilitate  diffusion. 

Watch  for  poor  pulse,  cyanosis,  embarrassed  breathing,  collapse 

and  let  serum  flow  back  until  improvement  occurs. 
Keep  the  needle  hi  situ  for  a  few  minutes  to  avoid  necessity  for 

another  puncture,  if  symptoms  develop  (Dunn). 
Remove  excess  iodine  with  alcohol.     Seal  puncture  with  sterile 

gauze  pad. 
If  bad  symptoms  develop  as  above, 

Do  artificial  respiration. 

Cocaine  hydrochloride,  gr.  1/8-1/4  (0.008-0.015  Gm.)  hypoder- 
mically  (Sophian). 

Atropine  sulphate,  gr.  1/80-gr.  1/50  (0.00075-0.001  Gm.).    Adult 

dose. 

Children,  dose  gr.  1/800  to  gr.  1/100  (0.00008-0.0006  Gm.). 
Reaction. 

As  a  rule  none  of  consequence.    May  be  headache,  pain  in  back 

and  limbs. 
Raise  the  pillow. 
Morphine  sulphate,  dose,  smallest  that  will  relieve  pain,  gr.  1/48  to 

gr.  1/4  (0.0015-0.015  Gm.). 
Dry  tap. 

Usually  due  to  failure  in  technique. 

Canal  is  not  entered. 

Needle  is  plugged  with  tissue. 

Try  a  space  above  or  below. 

Fluid  may  be  inspissated. 

Sitting  patient  up  may  initiate  the  flow;  gentle  aspiration  with 

syringe  may  be  effectual. 
Saline  irrigation  or  serum  under  slight  pressure,  two  needles  in 

adjacent  spaces  with  saline  irrigation. 
True  dry  tap. 

Use  small  amount  of  serum  under  gentle  pressure  at  shorter  intervals. 
Early  usage  of  first  importance. 
(For  statistics,  see  text.) 

Possible  bad  results. 

(See  text.) 


CEREBRQ-SPINAL  MENINGITIS  587 

Intravenous  treatment 

Simultaneous  intraspinal  therapy  if  signs  of  meningitis  occur. 
Begin  as  soon  as  diagnosis  can  be  made  by  symptoms  and  positive 
blood  culture. 

Method. 

Desensitize  patient  by  subcutaneous  injection  of  1  c.c.  of  horse 
serum. 

After  one  hour  an  intravenous  injection  of  80-150  c.c.  of  anti- 
meningococcic  serum.    (See  text  for  details.) 

Frequency. 

Every  8-12  hours  until  desired  reaction  occurs.    Average  4-5  injec- 
tions. 

Fulminating  cases. 

More  frequent  doses,  twelve  hours  or  less  (Dunn). 
Also  intravenously  in  doses  of  75-100  c.c.  are  urgent  early. 

Chronic  cases. 
Continue  treatment  as  long  as  diplococci  persist,  or  there  are  active 

symptoms,  such  as  fever  and  pain.     Change  the  serum  used  as 

possibly  elaborated  from  different  strains. 
Stiff  neck  and  Kernig's  sign  may  outlast  the  infection. 
Give  a  dose  four  days  in  succession,  then  wait  a  few  days,  another 

series  and  so  on,  until  signs  disappear  (Dunn) .    Try  effect  of  drain- 
age alone  for  a  few  days. 
Sophian  uses 

Meningococci  vaccine  in  addition  to  the  serum. 

Begin  with  50,000,000   and    increase  up   to   1,000,000,000  or 
1,500,000,000. 

Give  at  three  to  five  day  intervals. 

Hydrocephalus. 

Tap  every  day  or  once  in  two,  three  or  four  days  according  to  symp- 
toms. 

Posterior  basic  meningitis. 

Tap  ventricles  daily  or  less  often  according  to  symptoms. 

Intradural  injection  of  serum  dangerous. 

If  ventricular  fluid  is  infected  inject  serum  into  ventricles  as  into 

cord. 

Tapping  ventricles. 
Infants. 
Enter  by  anterior  fontanelle  at  lateral   border,   push  needle 

down,  back  and  in  2  to  4  c.m. 
Use  same  needle  as  in  lumbar  puncture. 
Older  individuals. 
Trephine. 

Complications. 

Mental  disturbances. 
Frequent  tapping. 


588  TREATMENT  OF  ACUTE  INFECTIOUS  DISEASES 

Serum. 
Vaccines. 

Eye. 

Special  treatment. 
Serum  applied  locally. 
Panopthalmitis  with  blindness. 
Oculo-motors  may  be  involved. 

Ear. 

Otitis. 

(For  treatment,  see  Scarlet  Fever,  Chap.  XVII.) 

Joints. 

Vaccines. 

Remove  fluid  and  inject  serum. 

Arthritis  (Salicylates,  see  Chap.  Ill,  Rheumatic  Fever). 

Pneumonia. 

(See  Pneumonia,  Chap.  IX.) 
Serum  under  skin  or  into  vein. 
Vaccines. 

Endocarditis. 

As  under  other  circumstances. 
Serum  into  vein  or  under  skin. 
Vaccines. 

Pyelitis. 
Urotropin. 
Vaccines. 
When  severe. 

Serum  under  skin  or  into  vein. 


Relapses. 

Treat  as  a  fresh  case. 

Exacerbations. 
Treat  vigorously  as  a  fresh  case. 

Prophylaxis. 

Individual. 

Passive  immunity. 
Serum  subcutaneously. 
Lasts  two  to  three  weeks. 
More  lasting  immunity. 
Vaccines. 

One  hundred  million,  a  week  later 


CEREBRO-SPINAL  MENINGITIS  589 

Five  hundred  million,  and  then  a  week  later 
One  billion. 

Carriers. 
Quarantine  until  discharges  are  twice  negative. 

Convalescence. 

Period  varies  greatly  depending  on  damage  done. 
Fresh  air,  sunlight,  good  food,  careful  nursing. 
Herrick  advises  vaccines  to  prevent  recurrences,  giving  50  to  200 
millions  of  killed  meningococci,  3-5  injections  at  6-day  intervals. 


CHAPTER  XXVI 

POLIOMYELITIS 
(INFANTILE  PARALYSIS) 

THIS  disease,  so  dreaded  because  of  its  frightfully  crippling  effects, 
is  undoubtedly  of  microbic  origin. 

A  minute  globular  organism,  so  minute  as  to  pass  through  the  pores 
of  a  Berkfeld  filter,  has  been  detected  in  the  central  nervous  system, 
cultivated  and  made  to  reproduce  the  disease  in  monkeys  by  Flexner. 

The  virus  is  conveyed  by  individuals  infected  or  commonly  by  "car- 
riers"; that  is,  those  who  having  been  in  contact  with  the  sick,  though 
not  themselves  infected,  can  carry  the  virus  to  a  susceptible  person  and 
infect  him. 

The  r61e  played  by  insects  in  transmitting  the  disease  is  questionable. 

The  portal  of  entry  seems  to  be  the  upper  air  passages,  especially 
the  nose,  and  the  virus  passes  from  here  to  the  olfactory  lobes,  spinal 
cord  fluid  and  thence  to  the  nervous  tissue  for  which  it  has  a  special 
affinity. 

Protection  of  the  Community.  The  focus  from  which  all  epi- 
demics radiate  is  the  patient  sick  with  the  disease  in  question.  Pro- 
tection begins  then  with  sufficient  isolation  of  this  individual,  so  that 
there  shall  be  no  immediate  contact  between  him  and  a  susceptible 
individual  and  this  can  be  readily  accomplished  when  understanding 
and  willingness  on  the  part  of  those  concerned  cooperate. 

But  another  source  of  infection  beside  the  patient  frankly  sick  is 
the  abortive  and  ambulatory  case  and  only  a  sufficiency  of  skill  in 
diagnosis  of  this  group  of  cases  can  be  of  avail  in  eliminating  him  as  a 
source  of  infection. 

Another  source  of  infection  is  the  "  carrier."  The  carriers  may  be 
divided  into  two  groups;  first,  those  who  have  been  in  contact  with 
the  sick  and  though  uninfected  themselves  carry  a  virulent  organism 
about  with  them  and  those  who  have  had  the  disease,  have  recovered 
and  yet  carry  about  virulent  organisms,  like  the  diphtheria  and  typhoid 
carriers.  Flexner  has  called  attention  to  these  four  groups.  Flexner  and 
Amos  have  concluded  that  healthy  and  chronic  carriers  are  rare. 

Isolation.  Those  in  contact  with  the  patient  should  be  kept  iso- 
lated, so  far  as  possible  for  three  weeks  and  if  this  is  not  possible 


POLIOMYELITIS  591 

should  at  least  avoid  contact  with  children;  children  should  not  be 
allowed  to  go  to  school  or  to  public  gatherings. 

It  is  believed  that  the  nasal  mucous  membrane  has  a  distinct  protec- 
tive action  against  infecting  organisms.  If  this  be  so  any  antiseptics 
used  in  the  shape  of  sprays  or  local  applications  which  in  any  measure 
injure  the  innate  protective  mechanism  may  lessen  this  protection.  For 
this  reason  the  use  of  sprays  is  of  a  doubtful  value. 

The  abortive  cases  are  to  be  especially  looked  for  in  epidemics. 

A  diagnosis  of  an  abortive  case  of  poliomyelitis  is  at  best  conjectural 
and  when  occurring  as  a  sporadic  case  scarcely  possible,  but  in  an  epi- 
demic symptoms  of  an  acute  infection,  in  which  the  febrile  reaction  is 
accompanied  by  excessive  irritability  and  hypersesthesia,  should  arouse 
suspicion;  sweating,  stiffness  of  the  neck  or  gastro-intestinal  symptoms 
may  be  accompanying  features. 

When  such  a  diagnosis  is  suspected  the  spinal  cord  fluid  should  be 
examined.  This  is  clear  and  shows  a  ground  glass  or  opalescent  appear- 
ance due  to  an  increase  of  the  number  of  leucocytes.  If  shaken  up  a 
foam  forms  that  lasts  from  one-half  to  one  hour  due  to  an  increase  of 
the  globulin  content.  These  tests  are  of  value  only  if  positive  and  in  the 
absence  of  blood. 

The  cytology  varies  with  the  stage  of  the  disease.  There  is  always  a 
pleocytosis.  As  a  rule  in  the  first  week  there  is  a  lymphocytosis,  though 
rarely  in  the  very  early  days  there  may  be  a  polynucleosis. 

The  globulin  is  scant  during  the  first  week,  but  increases  steadily  and 
is  in  excess  even  8  to  10  weeks  after  the  onset. 

Later  in  the  second  and  third  weeks,  the  cells  decrease,  the  proportion 
of  polymorphonuclears  decrease  and  the  proportion  of  lymphocytes  and 
mononuclears  increase.  The  globulin  reaction  becomes  more  striking. 
Rarely  do  the  cells  reach  a  thousand ;  more  commonly  a  few  hundred  or 
only  10  to  100.  The  reduction  of  Fehling's  solution  unlike  that  of 
cerebro-spinal  meningitis  persists. 

The  fluid  may  appear  normal. 

This  picture  may  be  given  by  tuberculous  meningitis  and  syphilitic 
myelitis,  so  there  is  absolutely  no  diagnostic  feature  in  the  symptoma- 
tology or  findings,  but  such  a  spinal  fluid  added  to  the  general  symptoms 
given  above,  occurring  during  an  epidemic  makes  a  diagnosis  of  poliomy- 
elitis fairly  certain  and  from  the  practical  standpoint  imperative.  The 
blood  shows  a  leucocytosis;  sometimes  as  high  as  30,000,  and  an  increase 
of  10  per  cent,  to  15  per  cent,  in  the  polymorphonuclears. 

These  cases  are  to  be  isolated  in  the  same  way  as  the  frank  cases 
and  those  exposed  to  such  a  case  treated  as  those  exposed  to  a  frank 
case. 


592          TREATMENT  OF  ACUTE  INFECTIOUS  DISEASES 

More  difficult  is  the  problem  of  chronic  carriers.  We  know  that  the 
infection  resides  in  the  secretions  of  the  nose  and  in  the  saliva  and  has 
been  found  in  the  tonsils  and  pharynx. 

The  organism  has  been  found,  described  and  cultivated  by  Flexner 
and  his  workers  and  the  infectivity  of  secretions  determined  by  inocula- 
tion into  monkeys,  but  a  ready  method  of  determining  the  infectivity  of 
the  secretions  of  suspected  "  con  tacts"  and  of  patients  recovered  from 
the  disease  awaits  elaboration.  In  the  meantime,  such  contacts  and 
convalescents  should  be  kept  especially  from  children. 

Isolation  of  the  Patient.  I  feel  that  sufficient  emphasis  has 
not  been  laid  on  complete  isolation  of  these  cases.  In  the  last  New 
York  epidemic  I  saw  and  treated  a  great  many  cases  in  the  open  wards 
and  did  not  see  a  spread  of  the  disease  within  the  ward,  but  I  believe 
that  the  rarity  of  cases  among  contacts  gives  us  a  false  sense  of  security. 
Hill's  studies  in  Minnesota  (quoted  by  Lovett  and  Richardson)  on  the 
relative  transmissibility  of  this  disease  with  other  well  known  contagious 
diseases  showed  that  22  per  cent,  of  those  exposed  to  Scarlet  Fever 
contracted  the  disease,  to  Diphtheria  17  per  cent.,  to  Infantile  Paralysis 
6  per  cent.  Studying  exposures  in  single  families,  40  per  cent,  contracted 
Scarlet  Fever,  30  per  cent.  Typhoid  Fever,  29  per  cent.  Diphtheria  and 
17  per  cent.  Infantile  Paralysis;  moreover,  in  some  epidemics  as  high  as 
40  per  cent,  of  houses  or  families  affected  showed  more  than  one  case. 

These  figures  as  well  as  the  knowledge  of  the  infectivity  of  the  dust 
from  infected  rooms  (Thro),  the  conveyance  of  the  disease  by  healthy 
individuals,  all  seem  to  me  to  demand  as  strict  an  isolation  for  these 
cases  as  for  Scarlet  Fever  and  I  recommend  the  rules  laid  down  in  that 
chapter  as  applicable  here.  See  Scarlet  Fever,  Chap.  XVII. 

Rules  for  Disinfection  in  the  Patient's  Room.  All  secretions 
and  excretions  should  be  destroyed,  those  from  the  nose  and  mouth  best 
received  on  rags  or  gauze  and  burned.  For  the  mode  of  disinfection  of 
secretions,  articles  in  use  about  the  patient,  clothes  and  bedclothes, 
see  Typhoid  Fever,  Chap.  XIV. 

Doctors  and  Nurses.  It  should  be  remembered  that  cases  have 
appeared  in  or  through  individuals  only  once  in  contact  with  a  patient 
and  that  a  short  time. 

The  physician  and  nurse  should  take  the  same  precautions,  then, 
as  when  treating  a  scarlet  fever  case  and  the  precautions  to  be  taken 
in  the  sick-room  and  on  leaving  the  sick-room  should  be  the  same.  See 
Scarlet  Fever,  Chap.  XVII. 

Room.  A  light,  well-ventilated  room  should  be  chosen,  stripped 
of  furniture,  carpets,  rugs,  hangings,  etc.,  leaving  bare  floors  or  linoleum, 
so  that  the  floors  and  wall  may  be  wiped  with  damp  cloths  occasionally 


POLIOMYELITIS  593 

and  these  destroyed;  for  it  has  been  shown  that  the  dust  of  a  room 
harboring  a  case  is  infective  and  capable  of  transmitting  the  disease. 

Such  a  room  should  be  screened,  for  it  is  possible  that  insects  may 
convey  the  disease,  as  they  probably  do  typhoid  fever  by  becoming 
contaminated  with  secretions;  for  virus  passes  through  the  gastro- 
intestinal canal  of  man  and  remains  active;  but  that  the  disease  is 
regularly  conveyed  by  an  insect,  e.  g.,  the  fly,  as  was  once  suspected,  is 
not  proven. 

A  convenient  bath  room  and  a  separate  exit  from  the  house  are  to  be 
considered  in  the  choice. 

Bed.  The  bed  should  be  of  the  hospital  type,  a  half  or  at  the 
most  three-quarter  bed,  of  iron  with  woven  wire  springs  and  a  firm 
mattress.  The  bed  should  be  made  with  care  (see  index),  and  the  sheets 
drawn  smooth  and  free  from  wrinkles. 

One  must  remember  the  great  hypersesthesia  and  paralysis  and  how 
much  a  well  made  bed  makes  for  comfort.  Moreover,  numerous  me- 
chanical contrivances  will  be  used  if  paralysis  and  contractures  develop 
and  this  type  of  bed  facilitates  such  efforts. 

Care  of  the  Body.  Cleansing  baths  of  warm  soap  and  water 
should  be  given  each  day  and  oftener  if  the  sweating  is  severe.  These 
are  to  be  followed  by  sterile  talcum  powders  in  abundance. 

The  mouth  is  cared  for  as  in  any  of  the  acute  infections  and  the  same 
measures  applied  to  the  care  of  the  nose  and  genitals.  See  Pneumonia, 
Chap.  IX. 

It  must  be  remembered,  however,  that  the  virus  is  present  in  the 
secretions  of  the  mouth  and  nose  and  that  all  secretions  should  be  burned 
or  otherwise  destroyed. 

The  nurse  remembering  the  danger  to  herself  in  handling  these  secre- 
tions should  wear  gloves  and  sterilize  her  hands. 

Diet.  During  the  acute  stage  the  diet  should  consist  of  milk 
or  milk  preparations,  cereals,  bread,  broths,  plain  or  fortified  with  cereal 
or  farinaceous  flours,  eggs,  custard,  rice,  ice-cream. 

Water  or  lemonade,  orangeade,  or  other  drinks  flavored  with  fruit 
juices  and  fortified  with  sugar  may  be  used. 

Later  a  liberal  diet  may  be  allowed  and  the  appetite  satisfied. 

Treatment  of  Symptoms.  When  the  diagnosis  is  made  or  sus- 
pected, the  patient  should  be  put  to  bed  for  the  most  important  part 
of  his  treatment,  rest. 

When  one  recalls  that  the  essence  of  the  disease  is  an  inflammatory 
and  degenerative  process  in  the  motor  centres  of  the  cord  and  bulb  it 
should  go  without  saying  that  they  should  rest;  and  that  means  that  the 
muscles  they  subserve  must  rest;  hence,  the  whole  body.  A  clue  to  the 


594  TREATMENT  OF  ACUTE  INFECTIOUS  DISEASES 

continuance  of  this  activity  of  the  process  is  given  by  the  persistence  of 
the  hypersesthesia.  When  this  disappears,  it  may  be  assumed  that 
repair  has  begun  in  the  centres. 

Until  this  time  the  patient  should  not  be  persuaded  to  try  the  para- 
lyzed or  paretic  limbs;  but  rather  forbidden  to  do  so.  Even  when  there 
are  no  constitutional  symptoms  or  hypersesthesia  accompanying  the 
paralysis  it  is  better  to  keep  the  patient  in  bed  for  a  couple  of  weeks. 

Bowels.  When  first  seen  a  cathartic  should  be  given.  Castor 
oil  3ii-5i  (8-30  c.c.)  a  salt,  Rochelle  or  Epsom  3j~5i  (4-30  Gm.)  accord- 
ing to  age  or  calomel  gr.  i  to  gr.  ii  (0.060-0.120  Gm.)  in  divided  doses, 
followed  by  a  salt. 

Later  cascara,  compound  licorice  powder  or  aloin  in  doses  suited 
to  the  age  may  be  given  or  milder  salines  such  as  liquor  magnesii  ci- 
tratis,  Hunyadi  water,  milk  of  magnesia  or  occasionally  stronger  salts 
as  above  or  castor  oil. 

Enemata  are  usually  necessary  even  when  cathartics  are  given, 
for  constipation  is  a  rather  striking  feature  and  more  marked  when  the 
abdominal  muscles  are  paretic. 

Urine.  In  the  early  days  retention  may  occur.  It  is  necessary 
then  to  be  on  the  lookout,  as  catheterization  may  be  necessary.  One 
should  try,  first,  however,  the  simple  device  of  running  water,  water 
sprinkled  on  the  hypogastrium  or  heat  or  cold  applied  to  the  hypogas- 
trium. 

PREPARALYTIC    PERIOD 

Specific  Treatment.  Efforts  to  accomplish  a  cure  by  specific 
therapy  has  been  made  along  two  different  routes.  First  by  the  use  of 
immune  sera  derived  from  a  horse  by  the  injection  of  the  organism 
responsible  for  the  disease  and  second  by  the  use  of  serum  from  a  patient 
convalescent  from  the  disease.  It  has  not  yet  been  definitely  settled 
what  is  the  etiological  agent  concerned  in  this  disease.  Claims  are  made 
by  Flexner  and  his  co-workers  at  the  Rockefeller  Institute  for  globoid 
organisms  which  pass  a  Berfeld  filter  and  by  Rosenow  of  Chicago  for  a 
pleomorphic  streptococcus.  Both  these  workers,  using  the  organisms 
they  have  isolated,  have  produced  an  immune  serum  which  each  has 
used  in  the  treatment  of  the  disease  with,  what  has  seemed,  satisfactory 
results.  The  serum  is  given  intraspinally,  intravenously  and  intra- 
muscularly. Nuzum  and  Willy  using  the  serum  obtained  with  the  Rose- 
now  organism  have  reduced  the  mortality  to  11.9  per  cent,  of  159  cases 
as  contrasted  with  38  per  cent,  in  100  cases  untreated  during  the  same 
period. 

Their  method  is  to  use  the  serum  as  early  as  possible,  giving  15-30 


POLIOMYELITIS  595 

c.c.  intravenously  very  slowly,  repeating  it  every  12  hours  if  neces- 
sary; at  the  same  time  they  give  5-15  c.c.  intraspinally  after  removing 
about  the  same  volume  of  spinal  fluid.  The  injection  should  be  made 
slowly  and  without  pressure  as  the  lumen  of  the  blood  vessels  is  dimin- 
ished by  the  perivascular  infiltration. 

They  claim  that  in  12  to  24  hours  there  is  a  critical  fall  of  temperature, 
a  slowing  of  the  pulse  and  a  general  improvement  in  the  patient.  If 
given  early  paralysis  may  be  prevented.  They  have  seen  paralysis  clear 
up  under  late  serum  treatment. 

Sera  from  patients  recovered  from  or  convalescent  from  acute 
poliomyelitis  was  used  in  the  epidemic  of  1916.  Opinions  differed  as  to 
the  efficacy  of  this  measure,  but  the  majority  agree  that  results  were 
similar  to  those  described  above  after  the  administration  of  immune 
horse  sera.  It  seems  to  me  to  offer  greater  promise  than  the  horse  serum 
and  I  should  always  use  it  in  preference  to  the  immune  horse  serum  when 
it  is  available. 

The  method  consists  of  drawing  blood  under  aseptic  conditions  from 
donors  convalescent  as  recently  as  possible,  and  who  are  shown  to  be 
free  from  syphilitic  taint  or  other  infection.  After  the  blood  is  allowed 
to  clot  at  room  temperature  it  is  placed  in  the  ice  box  to  await  separation 
of  the  serum.  The  serum  is  then  decanted  and,  if  possible,  centrifuged 
to  obtain  a  product  free  from  corpuscles  and  hemoglobin.  It  may  then 
be  given  fresh  or  inactivated  by  the  addition  of  sufficient  tricresol  to 
produce  a  final  product,  containing  0.2  per  cent,  of  tricresol,  i.  e.,  2  c.c. 
of  tricresol  to  998  c.c.  of  serum,  or  it  can  be  inactivated  by  heating  in 
a  water  bath  to  56°  C.  for  half  an  hour. 

The  method  of  administration  is  the  same  as  outlined  above  for 
immune  horse  serum.  The  size  of  the  intraspinal  dose  should  not  be 
more  than  15  c.c.  and  introduced  only  after  the  removal  of  an  equal  or 
greater  quantity  of  fluid.  The  size  of  the  dose,  too,  is  modified  by  the 
knowledge  that  sera  obtained  from  patients  recovered  years  before 
rather  than  months  is  apt  to  be  less  potent.  The  serum  should  be  given 
intravenously  at  the  same  time.  The  dose  is  limited  only  by  the  diffi- 
culty of  obtaining  the  serum.  One  would  give  40-60  c.c.  or  even  more  if 
the  quantity  at  hand  is  abundant.  The  repetition  of  the  dose  depends  on 
the  severity  of  the  toxemia  and  the  reaction  of  the  patient  to  the  serum 
and  upon  the  degree  of  pleocytosis  in  the  spinal  fluid. 

The  serum  must  be  administered  early  in  the  disease  to  prevent 
paralysis.  It  is  still  a  question  what  effects  the  serum  may  have  upon 
paralysis  already  established.  Draper  says  that  "  generally  speaking 
patients  who  show  counts  below  100  in  the  first  twelve  to  eighteen  hours 
are  less  apt  to  develop  paralysis  then  those  who  show  500  or  more." 


596  TREATMENT  OF  ACUTE  INFECTIOUS  DISEASES 

Fever  occurs  in  this  period  and  disappears  soon  after  the  on- 
set of  paralysis.  It  is  not  a  feature  of  the  disease  and  requires  no 
treatment. 

Hyperaesthesia,  pain  and  sensitiveness  of  muscles  or  limbs  to 
pressure  or  handling  are  characteristic  if  not  constant. 

Hyperaesthesia  and  fear  of  pain  on  handling  lead  to  striking  irri- 
tability to  which  undoubtedly  meningeal  involvement  adds. 

The  pain  may  be  spontaneous  or  elicited  only  on  handling.  These 
discomforts  are  usually  more  marked  in  paralyzed  limbs,  but  may  occur 
in  limbs  which  are  not  paralyzed  and,  indeed,  during  the  paralytic 
period. 

The  discomfort  induced  by  movements  often  causes  the  child  to 
hold  the  part  so  quiet  that  it  simulates  paralysis. 

Even  the  weight  of  the  bed-clothes  may  cause  distress  and  in  such 
cases  cradles  over  the  limb  to  support  the  clothes  are  helpful.  At  times 
the  application  of  a  light  splint  to  immobilize  a  limb  is  grateful  to  the 
patient. 

Heat  is  especially  soothing  and  may  be  applied  as  fomentations 
or  with  the  hot- water  bag ;  wrapping  the  part  affected  in  a  thick  layer 
of  cotton  batten  subserves  the  same  purpose. 

Drugs.  When  irritability  is  the  preponderating  feature,  bromides, 
either  the  potassium  salt  or  triple  bromides  may  be  given  with  benefit. 

When  pain  is  dominant  a  member  of  the  coal-tar  group,  phenacetin, 
antipyrin  or  acetanilid  is  indicated.  (See  Summary  for  doses.) 

Salicylates,  such  as  the  sodium  salts  or  acetyl  salicylic  acid 
(aspirin)  are  less  depressing  than  the  aniline  derivatives  and  sometimes 
as  effectual. 

For  more  severe  pain  codeine  or  even  morphine  may  be  necessary. 
(See  Summary.) 

Sometimes  drowsiness  and  apathy  are  present  instead  of  irritability, 
but  even  then  wakefulness  may  be  a  feature. 

Insomnia  which  makes  such  inroads  on  strength  is  met  by  bromides 
or  a  mild  hypnotic  such  as  trional  sulphonethylmethane  or  by  codeine. 
Stiffness  and  pain  in  the  muscles  of  the  neck,  especially  on  bending  the 
head  forward  is  common  and  demands  care  in  handling  and  intelligent 
arrangement  of  the  pillows. 

Applications  of  heat  should  be  useful. 

Convulsions  are  very  rare  and  should  indicate  warm  packs  and 
morphine  to  control  the  convulsion  and  bromides  to  prevent  recurrence. 

Gastro-intestinal  symptoms  are  so  common  as  to  attract  atten- 
tion and  during  an  epidemic  a  febrile  attack  accompanied  by  vomiting 
should  elicit  suspicion  and  concern. 


POLIOMYELITIS  597 

The  vomiting  and  anorexia  demand  rest  for  the  stomach. 

The  food  is  stopped  entirely  or  cut  down  to  small  amounts.  Sodium 
bicarbonate  or  bismuth  may  be  used  but  it  is  not  commonly  persistent 
nor  requires  much  interference. 

Diarrhea  may  occur,  but  constipation  is  the  rule.  Severe  diar- 
rhea indicates  regulation  of  food;  castor  oil  and  bismuth  subnitrate. 

Tonsillitis  and  pharyngitis  are  sometimes  present  and  the  virus 
has  been  recovered  from  the  tonsils. 

Hot  saline  irrigations  may  be  used.  (See  Scarlet  Fever,  Chap. 
XVII.)  Sprays  of  mild  antiseptics  and  argyrol  15  per  cent,  to  25  per 
cent,  may  be  applied. 

Use  of  Urotropin  (Hexamethylenamine).  Because,  when  adminis- 
tered by  the  mouth,  this  drug  was  found  in  the  spinal  cord  fluid  and 
because  when  given  to  monkeys  it  was  thought  that  the  subsequent 
infection  was  modified  in  severity,  it  came  to  be  quite  extensively  used; 
but  careful  observations  of  clinical  results  following  its  use  holds  out 
no  hope  from  its  use  and,  moreover,  the  efficacy  of  urotropin  (hex- 
amethylenamine)  depends  upon  its  breaking  up  to  set  free  formalde- 
hyde. This  occurs  only  in  acid  and  not  in  alkaline  media  such  as  the 
cerebro-spinal  fluid. 

Pathology.  The  disease  has  been  called  a  meningo-encephalo- 
poliomyelitis,  and  this  term  will  explain  the  types  of  the  disease  we 
observe.  But  it  is  even  more  than  this  for  it  affects  both  the  white 
and  gray  matter  of  the  brain,  the  cord  and  the  intervertebral  ganglia 
and  the  abdominal  ganglia.  Flexner*s  studies  lead  him  to  this  con- 
clusion: that  the  route  of  infection  is  in  the  vast  majority  of  instances, 
practically  always,  by  the  nasal  mucous  membrane  to  the  lymphatic 
channels  of  the  olfactory  lobes,  to  the  cerebro-spinal  fluid,  by  this  to 
be  distributed  to  the  nerve  tissues  of  the  cerebro-spinal  axis,  for  which 
the  virus  has  a  special  affinity. 

Conveyance  by  the  blood  must  be  exceedingly  rare  in  human  beings 
and  curiously  enough  the  avidity  of  nerve  tissue  for  the  virus  is  not 
sufficient  to  derive  it  from  the  blood  vessels  unless  damage  has  pre- 
viously been  done  to  them  or  to  the  choroid  plexus. 

Types  of  the  Disease.  Wickman,  in  his  monograph  on  the  dis- 
ease, which  to  avoid  the  common  name  connoting  the  pathology,  he 
calls  in  honor  of  the  two  great  students  of  the  condition  the  Heine- 
Medin's  Disease,  divides  the  clinical  pictures  into  eight  types, 

1.  Spinal  (the  most  common)  poliomyelitis. 

2.  Landry's  paralysis  (ascending  or  descending  paralysis). 

3.  Bulbar  type. 

4.  Encephalic  or  cerebral  type. 


598  TREATMENT  OF  ACUTE  INFECTIOUS  DISEASES 

5.  Ataxic  type. 

6.  Polyneuritic  type. 

7.  Meningitic  type. 

8.  Abortive  type. 

These  types  are  not  clear  cut  and  merge  into  one  another. 
For  this  reason  fewer  and  more  inclusive  groupings  have  been  ad- 
vocated, such  as 

1.  Spinal  type. 

2.  Bulbar  type. 

3.  Cerebral  type. 

4.  Abortive  type.     (Miiller.) 
or 

1.  Upper  motor  neurone  type. 

2.  Lower  motor  neurone  type. 

3.  Abortive  type.    (Peabody,  Draper  and  Dochez.) 

The  abortive  type,  whose  symptoms  are  those  of  a  preparalytic 
period  has  been  discussed. 
Wickman  has  divided  this  Type  into  four  groups, 

1.  A  group  showing  symptoms  of  any  general  infection. 

2.  A  group  showing  much  meningeal  irritation  (meningism). 

3.  A  group  in  which  pain  is  a  feature  (influenza-like) . 

4.  A  group  with  predominant  gastro-intestinal  disturbance. 

These  serve  to  fix  the  attention  on  poliomyelitis  during  an  epi- 
demic. 

The  ascending  and  descending  spinal  types,  Landry's  paralyses, 
are  rare  and  highly  dangerous  types. 

The  polyneuritic  and  ataxic  types  are  among  the  rarer  manifestations 
of  the  disease. 

Meningo-encephalitic  Type.  As  has  been  said  sharp  differen- 
tiation between  the  types  of  Wickman  does  not  obtain;  hence, 
it  is  better  to  consider  the  meningeal  and  encephalitic  cases 
together. 

The  symptoms  are  such  as  one  might  expect  from  involvement  of 
the  brain  and  its  covering;  headache,  irritability,  restlessness  and  some- 
times convulsions.  In  some,  apathy  or  stupor  predominate;  vomiting 
is  likely  to  occur.  There  are  pain  and  stiffness  of  the  neck,  disturbances 
in  the  rhythm  of  pulse  and  respiration;  tache  cere*brale  and  there  may 
be  Kernig's  sign. 

As  the  hydrocephalus  develops  Macewen's  sign  may  be  noted  and  in 
infants  the  fontanelles  bulge.  The  involvement  of  the  centres  causes 
palsies,  facial,  monoplegias  or  hemiplegias,  opthalmoplegia,  increased 
reflexes  and,  later,  spasticity. 


POLIOMYELITIS  599 

These  symptoms  are  to  be  met  as  described  under  the  section  on  the 
preparalytic  period  and  under  cerebro-spinal  meningitis,  Chap.  XXV. 

Bulbo  Spinal  Type.  Again  a  sharp  differentiation  between  the 
bulbar  and  spinal  types  is  useless,  if  possible,  and  they  will  be  con- 
sidered together. 

This  is  the  common  well-known  type  of  the  disease  that  gave  to  us 
the  term  anterior  poliomyelitis. 

Most  authorities  recognize  distinct  stages  that  have  decided  signifi- 
cance from  the  standpoint  of  therapeutics. 

1.  The  acute  stage;  from  the  onset  to  and  through  the  spread  of 
paralysis. 

2.  The  stage  of  recovery  in  those  muscles  capable  of  recovery. 

3.  The  stage  of  residual  and  permanent  paralysis. 

The  Acute  Stage.  All  that  pertains  to  the  general  symptoms  of 
this  stage,  aside  from  the  paralysis  has  been  dealt  with  above  under 
the  pre-paralytic  period. 

The  essence  of  the  therapy  is  rest  of  function  of  the  affected  parts 
and  hence,  the  inflamed  cord  centres  supplying  those  parts.  Rest  means 
not  only  a  comfortable  bed,  careful  nursing,  devices  to  find  comfortable 
positions  for  the  painful  members,  but  also  freedom  from  excitement, 
entertainment  and  visitors  and,  particularly,  avoidance  of  pernicious 
measures  of  mechanico-  or  electro-therapeutics,  often  insisted  on  by  the 
parents  in  an  eagerness  to  see  something  done  for  the  condition. 

Beside  affording  rest  we  ameliorate  the  discomforts. 

Lovett  calls  attention  to  the  importance  of  recognizing  the  tendency 
to  contracture  in  these  first  two  or  three  weeks  and  taking  measures  to 
prevent  it.  This  is  especially  likely  to  occur  in  the  Achilles  tendon. 
Lovett  advises  gentle  stretching  of  the  muscles  and,  as  a  prevention,  a 
box  covered  with  a  blanket  placed  at  the  bottom  of  the  bed  against  which 
the  soles  of  the  feet  may  rest  and  preserve  for  the  feet  a  right  angle  to 
the  legs.  The  weight  of  the  bed-clothes,  which,  pressing  on  a  paralyzed 
part,  exaggerates  the  deformity  and  encourages  contracture,  must  be 
taken  off  by  wire  cages,  stretching  clothes  across  the  crib  or  similar 
devices.  Light  splints  may  be  applied  to  correct  the  position;  pillows 
and  folded  blankets  may  be  used  for  the  same  purpose  and  the  position 
of  a  joint  should  be  changed  from  time  to  time. 

The  best  guide  to  the  length  of  the  period  of  the  active  cord  involve- 
ment is  the  continuance  of  tenderness  in  the  muscles  and  joints.  It  may 
last  two  or  three  months  and  during  this  time  no  active  measures  should 
be  applied  to  the  affected  muscles.  When  the  bulb  is  affected  one 
may  see  ocular  palsies,  facial  palsy  and  involvement  of  the  tongue,  the 
pharynx  and  muscles  of  deglutition.  These  latter  may  compel  feeding 


600  TREATMENT  OF  ACUTE  INFECTIOUS  DISEASES 

by  nasal  or  stomach  tube  and  entail  constant  care  to  keep  the  mouth 
and  pharynx  free  from  secretions  and  food  particles  that  may  induce  a 
foreign  body  pneumonia. 

Involvement  of  Muscles  of  Trunk  and  Diaphragm.  Paralysis 
of  the  respiratory  muscles  is  the  usual  cause  of  death.  The  intercostal 
muscles  are  almost  always  affected  before  the  diaphragm. 

Death  due  to  this  cause  may  be  direct  or  due  to  pulmonary  com- 
plications sequential  to  the  paralysis. 

Either  set  of  muscles  are  capable  of  carrying  on  the  respiration.  It  is 
the  involvement  of  both  that  is  fatal. 

In  what  seems  extensive  involvement  of  these  muscles  hope  lies 
in  the  fact  that  improvement  may  be  rapid  and  substantial  because 
the  depression  of  centres  often  overflows  the  site  of  actual  damage. 
When  the  dyspnoea  becomes  accentuated  oxygen  may  be  administered 
and  respiratory  stimulants  such  as  atropine,  caffeine  and  strychnine 
may  be  given  hypodermically  and,  these  failing,  artificial  respiration 
tried,  but  when  one  bears  in  mind  the  pathological  basis  of  this  failure 
in  function  he  realizes  how  futile  these  measures  must  necessarily  be. 

The  paralysis  of  the  abdominal  muscles  greatly  aggravate  constipa- 
tion and  makes  the  patient  more  dependent  on  cathartics  and  enemata. 

Retention  of  urine  must  be  borne  in  mind  and  the  measures  described 
above  undertaken. 

Paralysis  of  the  Extremities.  The  distribution  of  the  paralysis 
is  weird,  often  affording  combinations  topographically  and  functionally 
remote  from  each  other. 

The  legs  are  involved  more  commonly  than  the  arms  and  one  leg  more 
commonly  than  both.  The  onset  of  the  paralysis  is  lawless;  it  being  the 
first  manifest  symptom  in  some  cases  or  occurring  any  day  after  the 
onset,  though  the  majority  of  cases  show  paralysis  within  three 
days.  However,  the  onset  of  the  paralysis  may  be  delayed  a  week  or 
two. 

Again  it  is  difficult  to  forecast  the  extent  of  the  ultimate  paralysis 
by  the  extent  in  the  early  days,  for  the  early  paralysis  may  be  due  to 
other  causes  than  actual  cell  destruction  such  as  edema  and  pressure 
of  exudate  on  centres,  depressing  effects  of  toxins  on  centres,  or  only 
partial  and  not  necessarily  an  eventual  crippling  involvement  of  a 
group  of  cells ,  in  the  cord,  so  that  in  a  very  extensive  early  paralysis 
complete  recovery  or  slight  damage  only  may  follow.  Unhappily  there 
is  the  obverse  of  the  shield  and  prognosis  waits  on  time. 

What  is  to  be  done  in  the  acute  stage  and  even  more  important  what 
is  not  to  be  done  has  been  detailed  above. 

When  the  acute  process  has  subsided  (see   above)  one  should 


POLIOMYELITIS  601 

begin  the  treatment  with  massage.  Massage  must  be  begun  gently 
and  for  short  periods  of  time  at  first;  gradually  increasing  up  to  fifteen 
to  twenty  minutes  two  or  three  times  a  day. 

Heat  in  the  shape  of  hot  applications  or  baking  is  a  useful  ad- 
juvant to  the  massage.  Electric  light  bulb  suspended  from  a  cradle 
makes  a  simple  hot  air  bath.  Care  must  be  taken  lest  excessive  heat 
damage  the  tissues. 

In  this  way  the  nutrition  and  tone  of  the  muscle  is  subserved. 

Electricity  probably  has  a  very  limited  value.  Its  use  has  un- 
doubtedly been  greatly  abused  and  led  to  the  neglect  of  more  valuable 
measures,  less  striking  in  their  exposition  and  requiring  more  skill 
and  perseverance. 

Galvanism  is  applied  to  the  nerve  trunks  and  faradism  to  the  muscles, 
if  they  will  respond  to  faradism.  Galvanism  is  supposed  to  affect  the 
nutrition  of  the  muscles  the  more,  but  the  contraction  under  the  faradic 
current  constitutes  a  more  distinct  exercise. 

Passive  Movements.  Passive  movements  play  an  important  part 
in  the  prevention  of  contractions,  as  has  been  noted  above.  They 
also,  like  massage,  have  a  favorable  effect  upon  the  contraction  in  the 
affected  part. 

Active  Movements.  There  is  no  doubt  that  the  best  exercise  is 
that  developed  along  normal  lines;  that  is  voluntary  movements. 

It  must  be  remembered  that  the  extensive  distribution  of  motor  cen- 
tres governing  any  group  of  muscles  is  in  a  longitudinal  direction  and  that 
some  centres  are  very  likely  to  escape  and  that  these  centres  may  be 
educated  to  take  on  the  function  of  the  destroyed  centres  in  no  small 
degree.  Persistency  is  all  important.  In  intelligent  adults  an  under- 
standing of  the  problem  is  of  great  assistance,  but  the  vast  majority  of 
the  patients  are  children  and  very  many  of  them  little  children,  so  that 
cooperation  on  their  part  has  to  be  elicited  by  indirect  methods. 

The  warm  bath,  affording  both  heat  and  buoyancy,  has  been  advised, 
in  which  the  child  is  persuaded  to  effort  by  a  desire  to  play  with  floating 
toys,  or  similar  devices  by  which  strong  desire  is  made  to  elicit  voluntary 
effort  may  be  resorted  to. 

In  older  children  efforts  may  be  systematized. 

At  first,  assistance  must  be  given  by  the  operator  to  effect  the  pro- 
posed movements,  but  as  the  patient's  ability  is  increased  less  and  less 
help  is  given,  then  resistance  exercises  are  begun  in  which  the  operator 
makes  gentle  and  then  increasing  opposition  to  the  patient's  movements. 

How  long  these  exercises  shall  be  persisted  in  before  recourse  to 
mechanical  expedients  is  had  is  a  nice  question,  but  it  should  be  months. 
Good  authority  puts  it  at  a  year  and  a  half  to  two  years,  and  even 


602  TREATMENT  OF  ACUTE  INFECTIOUS  DISEASES 

then  one  is  not  sure  that  improvement  may  not  go  on,  even  when  it  has 
been  discouragingly  slow. 

If  the  patient  has  achieved  all  he  can  with  the  impaired  muscles 
he  still  may  so  educate  other  groups  01  muscles  that  they  may  take  over 
the  function,  in  some  measure,  of  those  rendered  helpless  by  the  lesion. 

In  the  case  of  the  legs,  the  effort  to  walk  should  be  made,  but  in  a 
severe  case  this  is  obviously  impossible  without  mechanical  appliances 
to  afford  help. 

Apparatus.  The  apparatus  may  take  the  form  of  crutches,  corsets, 
jackets,  braces  or  splints  and  is  distinctly  an  orthopedic  problem  and 
competent  authority  should  be  sought. 

At  last  the  problem  may  become  a  distinctly  surgical  one  and, 

Operative  Treatment  Is  Indicated.  Lovett  in  a  masterly  article 
outlines  the  indications  as  follows: 

1.  To  correct  fixed  deformity. 

2.  To  improve  muscular  function. 

3.  To  secure  stability  of  useless  joints. 

Such  operations  are  instanced  by  transplantation  of  a  tendon  of 
an  active  muscle  to  the  insertion  of  a  paralyzed  muscle  to  take  over 
the  function  of  the  latter.  This  should  not  be  an  early  operation  but 
undertaken  only  when  failure  to  improve  in  the  paralyzed  muscle  is 
without  question. 

Efforts  to  stabilize  flail  joints  by  arthrodesis,  or  an chy losing  of  joints 
by  removing  their  articular  cartilages  and  getting  bony  union  between 
the  members  of  the  joints. 

This  is  especially  applicable  in  the  ankle,  but  such  operations  should 
not  be  undertaken  without  first  carefully  acquainting  oneself  with  the 
indications  and  contraindications  in  individual  joints. 

Other  devices  may  take  the  place  of  arthrodesis,  such  as  the  use  of 
silk  ligaments  mentioned  by  Lovett. 

Contractures  may  require  cutting  and  stretching;  especially  about 
the  ankle  and  knee. 

Prognosis.  The  mortality  runs  about  15  per  cent.,  but  varies  in 
different  epidemics  and  at  different  ages. 

The  percentage  of  recoveries  investigated  in  one  series  of  234  cases 
(quoted  by  Lovett)  showed  25  per  cent,  to  be  complete  and  in  another 
series  of  fifty-seven  cases  28  per  cent,  completely  recovered  and  31  per 
cent,  more  recovered  function,  but  showed  some  atrophy.  The  mor- 
tality varies  in  different  epidemics  and  in  one  considerable  series  showed 
less  than  10  per  cent. 

It  seems  to  be  higher  in  infancy  and  after  ten  years  than  between 
these  periods. 


POLIOMYELITIS  603 

Prognosis  of  extent  of  damage.  This  is  difficult  to  determine  in  the 
acute  stage,  for  as  has  been  said,  what  seems  like  an  extensive  damage 
involving  trunk  muscles  may  clear  up  entirely  or  the  apparent  damage 
may  persist  and  spread  and  in  rare  cases  the  lesion  may  light  up  again 
after  subsidence  of  acute  manifestations. 

Muscles  which  contract  at  all  after  the  acute  symptoms  subside 
hold  out  hope  of  recovery  in  part  or  whole  and  efforts  to  improve  the 
power  of  such  muscles  should  be  persisted  in  for  many,  many  months. 

A  single  muscle  in  a  group  functionating  in  common  is  more  likely 
to  recover  than  when  associated  in  its  paralysis  with  more  members  of 
the  group  or  the  group  as  a  whole,  in  its  paralysis. 

SUMMARY 

Isolation. 

Of  "contacts"  for  three  weeks. 

Use  of  mild  antiseptic  sprays  for  the  nose  and  throat  by  "con- 
tacts," e.  g.,  1  per  cent,  official  peroxide  of  hydrogen,  of  doubtful 
value. 

Look  for  abortive  and  ambulatory  cases.    (See  text.) 
Of  patients. 

(See  summary  of  Scarlet  Fever,  Chap.  XVII.) 

Disinfection  of  patient's  room. 

(See  summary  of  Typhoid  Fever,  Chap.  XIV.) 

Doctors  and  nurses. 

(See  summary,  Scarlet  Fever,  Chap.  XVII.) 

Room. 

High  and  well  ventilated. 

Near  bath  room. 

Strip  of  furniture  and  furnishings. 

Screen. 

Bed. 

Half  or  three-quarters.    Hospital  type  preferred. 
Woven  wire  springs;  firm  mattress. 

Care  of  body. 

Cleansing  baths  of  soap  and  warm  water. 

Sterile  talcum  powders. 

Mouth. 

(See  Pneumonia  summary,  Chap.  IX.) 

Burn  secretions.  They  contain  the  virus.  Nurse  should  wear 
gloves  in  handling  them. 


604  TREATMENT  OF  ACUTE  INFECTIOUS  DISEASES 

Diet. 

Acute  stage. 

Milk,  milk  preparations,  cereals,  bread,  broths  thickened  with 
cereal  or  farinaceous  flours,  eggs,  Custard,  rice,  ice-cream. 

Water,  fruit  juice  drinks,  such  as  lemonade,  orangeade. 

May  fortify  with  sugar. 
After  acute  stage. 

Liberal  diet.    Satisfy  appetite. 

Treatment  of  symptoms. 

Rest,  of  body  and  especially  the  limbs  and  muscles  impaired;  the 

latter  until  all  hyperaesthesia  has  disappeared. 
Do  not  urge  patient  to  move  muscles,  j 

Do  not  massage.  |  During  the  acute  stage. 

Do  not  use  electricity. 

Bowels. 

Castor  oil  Sti-gi  (8-30  c.c.). 
Salts  (Epsom,  Rochelle)  3i~5i  (4-30  Gm.). 
Calomel,  gr.  i  to  gr.  ii  (0.060-0.120  Gm.), 
followed  by  a  salt. 
All  these  in  dose  according  to  age. 
Later. 

Cascara,  compound  licorice  powder,  aloin,  liquor  magnesii  citratis, 

milk  of  magnesia,  Hunyadi  water;  dose  according  to  age. 
Occasionally  a  stronger  salt  or  castor  oil. 
Enemata.    Required  especially  when  abdominal  muscles  are  paretic. 

Urine. 

Watch  for  retention. 
Try  running  water. 
Sprinkle  water  on  hypogastrium. 
Heat  to  bladder. 
Cold  over  bladder. 
Catheterize. 

Preparalytic  period. 

Convalescent  serum. 
More  valuable  than  immune  horse  serum.    (For  method  of  obtaining, 

see  text.) 

Administered  both  intravenously  and  intraspinally. 
Method  of  administration.    (See  Cerebro-spinal  Fever,  Chap.  XXV.) 
Dose  by  vein  20, 40,  60  c.c.,  depending  on  quantity  of  serum  available. 
Intraspinally  not  more  than  15  c.c.  after  the  removal  of  an  equal  or 

greater  amount  of  spinal  fluid.    Frequency  depends  on  toxemia, 

reaction  and  pleocytosis  of  the  spinal  fluid. 
Must  be  administered  early. 


POLIOMYELITIS  605 

Immune  horse  serum. 

Time  of  administration  early  as  possible. 

Dosage  15-30  c.c.  intravenously  very  slowly. 

Repetition  every  12  hours  until  favorable  reaction  obtained. 

Simultaneously  give  5^-15  c.c.  intraspinally  after  removing  an  equal 

volume  of  spinal  fluid. 
Fever. 

Rarely  requires  attention. 
Luke-warm  water  sponges. 
Hyperaesthesia,  pain,  sensitiveness  of  muscles. 

Remove  weight  of  bedclothes,  by  cradles  and  similar  devices. 
Light  splints  to  painful  limbs. 
Heat. 

Fomentations. 
Hot-water  bag. 

Wrap  part  in  thick  layer  of  cotton  batten. 
Drugs. 
Bromides,  especially  when  there  is  much  irritability,  gr.  v  to  gr.  xv 

(0.35-1.0  Gm.)  three  or  four  times  a  day,  according  to  age. 
Phenacetin,  gr.  iss.  to  gr.  xv  (0.1-1.0  Gm.),  according  to  age. 
Antipyrin,  gr.  i  to  gr.  x  (0.060-0.65  Gm.),  according  to  age. 
Acetanilid,  gr.  ss.  to  gr.  v  (0.030-0.35  Gm.),  according  to  age. 
Lesser  doses,  say  one-third,  may  be  repeated  at  two,  three  or 

five  hour  intervals. 
Salicylates. 

Sodium  salicylate  or  aspirin  (acetyl  salicylic  acid), 
gr.  i  to  gr.  xx  (0.060-1.35  Gm.),  according  to  age. 
These  doses  may  be  repeated  at  two,  three  or  four  hour  intervals 

if  pain  continues. 
Codeine  phosphate  or  sulphate. 
For  more  severe  pain. 

gr.  1/48  to  gr.  1/4  (0.0015-0.015  Gm.),  according  to  age. 
Morphine  in  most  severe  cases. 

gr.  1/120  to  gr.  1/4  (0.0005-0.015  Gm.),  according  to  age. 
Insomnia. 

Bromides,  gr.  v  to  gr.  xxx  (0.35-2  Gm.),  according  to  age. 
Trional,  gr.  i  to  gr.  x  (0.060-0.65  Gm.).  according  to  age. 
Codeine  sulphate  or  phosphate,  gr.  1/48  to  gr.  1/4  (0.0015-0.015 

Gm.),  according  to  age. 
Stiffness  and  pain  in,  muscles  of  the  neck. 
Heat. 

Fomentations. 
Convulsions. 
Rare. 

Warm  packs. 

Morphine  sulphate  to  control,  gr.  1/48  to  gr.  1/4  (0.0015-0.015 

Gm.),  according  to  age. 

Bromides  to  prevent  occurrence,  gr.  v  to  gr.  xv  (0.35-1.0  Gm.) 
every  three  to  four  hours. 


606  TREATMENT  OF  ACUTE  INFECTIOUS  DISEASES 

Gastro-intestinal. 

Vomiting. 
Stop  food. 

Sodium  bicarbonate,  gr.  v  to  gr.  xv  (0.35-1.0)  in  water.' 
Bismuth   subnitrate   or   subcarbonate,  gr.   v.  to  gr.  xv  (0.35- 
1.0  Gm.)  suspended  in  water. 

Diarrhea. 

Regulate  food,  cut  down  cream  and  sugar  in  milk. 

Give  castor  oil  Sii-gss.  (8-15  c.c.). 
Follow  with 
Bismuth  subnitrate,  gr.  xv  to  gr.  xxx  (1-2  Gm.)  every  two 

hours. 
Tonsillitis  and  pharyngitis. 

Hot  saline  irrigations,  argyrol  15  per  cent,  to  20  per  cent. 
(See  summary  in  Scarlet  Fever,  Chap.  XVII.) 
Urotropin.    (Hexamethylenamine.) 
(See  text.) 

Paralytic  period. 
Rest  to  paralyzed  limbs. 
Avoiding  contractions. 
Gentle  stretching  of  muscles. 
Rest  at  bottom  of  bed  for  soles  of  feet  in  drop  of  foot. 

A  box  covered  with  a  blanket  sufficient. 

Take  weight  of  clothes  from  paralyzed  parts  with  cradles  and  sim- 
ilar devices. 

Light  splints  to  correct  position. 
Pillows,  folded  blankets,  for  same  purpose. 
Change  position  of  joint  from  time  to  time. 
Bulbar  type. 

Muscles  of  deglutition  involved. 

Keep  mouth  free  from  secretions  and  food  particles. 

May  have  to  feed  with  stomach  or  nasal  tube. 
Involvement  of  respiratory  muscles. 
Dyspnoea. 

Oxygen  inhalations. 

Atropine  sulphate  hypodermically,  gr.  1/1000  to  gr.  1/60  (0.00006- 
0.001  Gm.),  according  to  age. 

Caffeine  sodio-salicylate  or  benzoate,  gr.  1/4  to  gr.  v  (0.015-0.35 
Gm.)  or 

Strychnine  sulphate,  gr.  1/500  to   gr.  1/30   (0.00012-0.002   Gm.) 

hypodermically,  according  to  age. 
Artificial  respiration. 

Paralysis  of  extremities. 
After  acute  stage  subsides. 
Massage. 

Gentle  at  first  for  very  short  time.    Increase  up  to  15-20  min- 
utes two  or  three  times  a  day. 


POLIOMYELITIS  607 

Heat. 

Fomentations. 

Baking. 
Electricity. 

Galvanism  to  nerve  trunks. 

Faradism  to  muscles  that  respond. 
Passive  movements. 

To  prevent  contractions. 

To  improve  circulation  in  affected  structures. 
Active  movements. 

Best  method  to  develop  impaired  centres  and  muscles. 

Keynote  of  success  is  persistency. 

Warm  bath  a  valuable  adjuvant.    (See  text.) 
Resistance  exercises. 
Apparatus. 

Crutches,  corsets,  jackets,  braces,  splints. 
Operative  treatment. 

Transplantation  of  tendons. 
Arthrodesis. 
Silk  ligaments. 
Operation  for  contractures. 

Prophylaxis. 

Avoidance  of  contacts. 

Isolation  of  patient. 

Destruction  of  secretions. 

Members  of  affected  families  to  avoid  contact  with  children  and 

crowded  places. 
Children  to  avoid  gatherings  of  children  during  an  epidemic. 

Schools  are  common  centres  of  the  spread  of  the  disease. 
Avoid  taking  children  to  affected  localities,  especially  in  summer. 


CHAPTER  XXVII 

SMALL  POX 

(VARIOLA) 

SMALL  pox  still  jealously  guards  the  secret  of  its  origin.  A  parasite, 
the  Cytorrhyctes  variolse,  first  described  by  Councilman,  bids  fair, 
however,  to  elucidate  the  mystery.  And  yet,  many  of  the  symptoms 
of  the  disease  must  be  attributed  to  the  concomitant  action  of  pyogenic 
organisms  and  in  all  probability  it  is  to  these  that  most  of  the  fatal 
issues  are  due. 

Jenner's  observation  that  individuals  who  had  suffered  from  cow  pox 
became  by  virtue  of  that  fact  protected  from  small  pox  and  his  applica- 
tion of  that  knowledge  in  terms  of  vaccination  constitutes  one  of  the 
most  dramatic  episodes  in  medical  history  and  is  too  familiar  to  want 
reiteration  here.  Jenner  furnished  the  means  of  eliminating  the  disease 
forever  and  only  ignorance  and  criminal  carelessness  or  wilful  neglect 
has  prevented  the  passing  of  what  once  was  a  scourge  to  the  human 
race. 

There  seems  to  be  among  physicians  a  wide-spread  belief  that  the 
infectious  organism  or  virus  may  be  conveyed  through  the  air  as  well  as 
by  contact,  which  makes  isolation  more  imperative  and  more  difficult; 
but  so  good  an  authority  as  Rosenau  doubts  any  other  mode  of  convey- 
ance than  a  direct  one,  through  discharges,  secretions  or  objects,  includ- 
ing insects,  in  contact  with  such. 

In  any  case  efficient  treatment  begins  with  isolation  as  soon  as  the 
diagnosis  is  made  or  even  suspected. 

Hospital  treatment  of  the  patient  is  preferable  both  from  his  stand- 
point and  that  of  the  community,  but  if  the  treatment  must  be  carried 
out  in  the  home,  the  physician  must  realize  that  a  greater  obligation 
rests  upon  him  to  establish  and  maintain  isolation  and  teach  the  family 
their  part  in  carrying  it  out.  Skillful  nurses  can  hardly  be  dispensed 
with. 

Room.  The  room  should  be  as  remote  from  the  rest  of  the  house- 
hold as  possible  with  a  separate  approach  from  the  outside  to  avoid 
unnecessary  contact  of  nurses  and  attendants  with  other  parts  of  the 
house  or  members  of  the  family.  It  should  be  light,  well  ventilated, 
kept  at  65°  F.  to  70°  F.  and  screened  against  insects,  whose  access 


SMALL  POX  609 

to  the  discharges  and  secretions  affords  a  highly  probable  mode  of  con- 
veyance. 

The  room  should  be  stripped  of  all  unnecessary  furnishings  and  its 
treatment  and  separation  from  the  rest  of  the  house  carried  out  as  in 
Scarlet  Fever,  see  Chap.  XVII. 

Ready  approach  to  a  bath  room,  itself  under  isolation,  facilitates 
the  work  about  the  patient.  An  open  hearth,  making  possible  destruc- 
tion of  discharges  on  the  spot  by  fire,  is  a  desideratum.  The  discharges 
should  always  be  burned.  Rules  for  disinfection  of  bedding,  towels, 
bed  clothes,  utensils,  etc.,  may  be  found  under  Typhoid  Fever,  Chap. 
XIV,  and  be  considered  as  applicable  here. 

Nurses.  If  the  nurse  has  not  had  the  disease,  she  or  he  should 
be  vaccinated  afresh.  The  nurse  should  consider  herself  as  isolated,  so 
far  as  compatible  with  her  duties.  A  separate  kitchen  should  be  afforded 
her  and,  if  this  is  not  possible,  all  dishes  and  utensils  should  be  treated 
like  those  used  by  the  patient.  If  she  goes  out  at  all  she  should  take 
every  precaution  not  to  convey  the  disease  and  follow  the  rules  laid  down 
for  a  nurse  attending  a  Scarlet  Fever  case.  See  Chap.  XVII. 

Treatment  of  Other  Members  of  the  Family  or  Exposed  In- 
dividuals. These  should  all  be  vaccinated  with  virus  from  more  than 
one  source  to  insure  a  "take."  It  is  certainly  desirable  to  quaran- 
tine those  exposed,  but  not  always  possible.  Those  who  show  a  suc- 
cessful vaccination  may  be  released  when  this  is  obvious;  others  kept  in 
quarantine  for  six  to  eighteen  days;  but  if  this  is  not  possible  they  should 
be  kept  under  the  closest  surveillance  for  the  incubation  period  of  sixteen 
to  eighteen  days,  and  isolated  on  the  slightest  suspicion  of  infection. 

The  apartments  vacated  by  a  small  pox  case  must  be  thoroughly 
disinfected  (see  Summary)  together  with  their  clothes,  toilet  articles, 
utensils,  tools  or  articles  with  which  they  may  have  come  in  contact 
since  their  infection. 

Physicians  should  look  upon  themselves  as  potential  sources  of 
danger  to  the  community.  Except  in  emergencies  they  should  make 
their  visit  to  the  patient  the  last  one  in  the  day  and  in  any  case  spend 
some  time  in  the  open  air  before  calling  on  another  patient.  They  should 
take  every  precaution  on  the  occasion  of  a  visit  to  avoid  contamination, 
should  make  their  visit  no  longer  than  is  necessary  to  do  their  full  duty 
to  the  patient  and  then  disinfect  themselves  as  thoroughly  as  possible  on 
leaving.  For  full  details  of  precautions  to  be  observed  by  the  physician 
on  his  visit,  see  Scarlet  Fever,  Chap.  XVII. 

Visitors  should  not  be  allowed  unless  circumstances  arise  that  make  it 
imperative  and  then  should  observe  all  those  precautions  specified  for 
the  physician. 


610  TREATMENT  OF  ACUTE  INFECTIOUS  DISEASES 

Bed.  The  best  bed  is  of  the  hospital  type,  an  iron  half  or  three- 
quarters  bed  with  woven  wire  spring  and  a  firm  mattress.  For  the 
details  of  bed-making,  see  Chap.  IX. 

In  very  severe  cases,  especially  with  skin  complications  such  as  boils, 
abscesses,  bed-sores,  an  air  bed  or  water  bed  may  add  greatly  to  the 
patient's  comfort. 

Diet.  With  the  onset  there  may  be  decided  anorexia  and  during 
this  period  no  effort  should  be  made  to  force  the  feeding.  The  diet 
should  be  preferably  milk  or  milk  preparations  or  if  patients  cannot 
take  milk,  and  the  vast  majority  of  those  who  say  they  cannot  are 
found  to  bear  it  well  on  trial,  one  may  use  cereal  waters,  cereal  "pre- 
pared foods"  used  extensively  in  infant  feeding,  then  broths  fortified 
with  cereals  or  farinaceous  flours  and  egg  albumin  water.  Later,  how- 
ever, consideration  must  be  had  for  the  theoretical  demands  of  the 
patient  and  a  fairly  high  caloric  diet  may  be  aimed  at.  The  rules  laid 
down  in  Typhoid  Fever,  Chap.  XIV,  are  applicable  here.  The  condition 
of  the  mouth  in  Small  Pox  makes  the  ingestion  of  food  more  difficult 
than  in  Typhoid  and  the  patient  must  not  be  nagged  and  fatigued  to 
ingest  definite  quantities  fixed  upon  by  these  theoretical  considerations. 

Water  should  be  given  in  abundance.  Definite  orders  should  be 
given  the  nurse  not  only  to  supply  the  patient's  demands  but  considering 
the  sicker  patients  too  sick  to  appreciate  their  needs  or  to  ask  for  water 
to  offer  it  to  them  every  hour  when  awake. 

Fruit  drinks,  lemonade,  orangeade,  etc.,  may  be  used  and  afford 
an  excellent  vehicle  to  carry  sugar,  the  food  value  of  which  contributes 
materially  to  the  patient's  needs. 

Alkaline  waters,  such  as  Vichy  or  carbonated  waters,  if  grateful, 
may  be  used. 

Care  of  the  Body.  One  has  but  to  visualize  the  lesion  to  real- 
ize the  great  discomfort  the  patient  must  suffer  and  the  amount  of 
nursing  skill  and  fidelity  required  to  contribute  to  his  comfort. 

Mouth.  During  the  pre-emptive  period  the  mouth  should  receive 
the  attention  usually  given  it  in  acute  infections. 

It  should  be  rinsed  after  each  feeding  with  water  and  then  with  2  per 
cent,  boric  acid  solution  or  half  to  quarter  strength  DobelTs  solution 
or  the  equivalent  in  one  of  the  many  milder  antiseptics  on  the  market, 
the  use  of  which  may  be  more  grateful  to  the  patient.  The  teeth  may  be 
cleansed  with  a  very  soft  brush  and  a  good  tooth  paste  or  with  a  cotton 
swab  on  a  toothpick  saturated  with  one  of  the  above  solutions,  particular 
care  being  taken  to  free  from  food  the  interstices  of  the  teeth  and  the 
dead  spaces  between  the  gums  and  cheek.  Dry  coating  on  the  tongue 
may  be  softened  by  half  strength  official  peroxide  of  hydrogen  and 


SMALL  POX  611 

scraped  with  edge  of  a  whalebone.  When,  however,  the  eruption  ap- 
pears, the  painful  vesicles  in  the  mouth  and  throat  add  much  to  the 
difficulty  of  affording  proper  care.  No  harsh  instrument  such  as  the 
toothbrush  or  whalebone  can  be  used.  The  same  solution  may  be  used 
but  irrigations  will  afford  comfort;  indeed,  much  the  same  measures  may 
be  used  as  in  Scarlet  Fever.  (See  Chap.  XVII.) 

When  the  mouth  is  foul,  permanganate  of  potash,  a  claret  colored 
solution,  1  to  4,000,  may  be  used  as  an  irrigation  or  this  may  be  preceded 
by  half  strength  peroxide  of  hydrogen.  Chlorate  of  potash  gargles  may 
be  used,  1  per  cent.,  or  less  if  painful.  Ulcers  may  be  touched  with  silver 
nitrate  solution,  5  per  cent,  to  10  per  cent.  When  the  throat  is  painful, 
ice  applied  to  the  neck  as  in  tonsillitis  may  afford  relief. 

Nose.  The  nose  should  be  kept  free  from  secretions,  by  the 
gentle  use  of  such  solutions  as  have  been  mentioned  in  the  care  of 
the  mouth,  as  sprays  and  by  cotton  swabs,  on  wooden  toothpicks  as 
applicators,  dipped  in  the  same  solutions.  Dried  secretions  may  be 
moistened  first  by  the  application  of  sweet  oil  or  vaseline. 

Eyes.  The  need  of  careful  attention  to  the  eyes  cannot  be  too 
much  emphasized.  At  the  height  of  the  eruption,  it  and  the  attendant 
edema  make  proper  care  of  the  eyes  no  easy  task. 

Boric  acid  solution,  2  per  cent,  to  4  per  cent.,  should  be  applied  on 
wipes  to  keep  the  lids  clean  and  be  dropped  in  the  eyes.  When  the  eyes 
close  from  the  edema  a  warm  boric  acid  solution  must  be  used  as  an 
irrigation,  the  point  of  a  glass  irrigating  nozzle  being  gently  forced 
between  the  lids.  To  prevent  the  lids  from  sticking  together  an  applica- 
tion may  be  made  to  their  edges  of  vaseline  or  gr.  i  (0.06  Gm.)  of  yellow 
oxide  of  mercury  to  3  i  (4  Gm.)  vaseline. 

Frequent  and  prolonged  applications  of  cold  compresses  dipped  in  a 
2  per  cent,  to  4  per  cent,  boric  acid  solution  or  physiological  salt  solution 
tend  to  lessen  the  edema  and  discomfort. 

When  the  conjunctivitis  is  very  severe,  5  to  20  per  cent,  argyroi 
solutions  are  useful  applications. 

When  corneal  ulcerations  occur  a  1  per  cent  solution  of  atropine  sul- 
phate should  be  used. 

Skin.  One  can  imagine  the  task  imposed  on  the  skill  of  the 
nurse  and  the  ingenuity  of  the  physician  to  keep  the  skin,  the  site  of 
a  multitude  of  pustules,  hot,  painful  and  itching,  in  even  relative  com- 
fort. In  the  pre-emptive  period,  sponge  baths  of  soap  and  warm  water 
are  proper  and  desirable,  but  during  the  height  of  the  eruption  sponge 
bathing  is  no  longer  feasible.  Some  authors  urge,  however,  the  use  of 
prolonged  warm  baths,  keeping  the  patients  immersed  for  hours  at  a 
time.  It  is  claimed  for  these  warm  baths,  that  they  reduce  the  fever, 


612  TREATMENT  OF  ACUTE  INFECTIOUS  DISEASES 

lessen  the  nervous  excitation,  are  a  sedative  to  the  skin  and  macerate  the 
pustules,  thus  effecting  an  earlier  discharge  of  their  contents.  Certainly 
the  procedure  seems  a  rational  one  and  the  criterion  of  its  success  is  the 
response  of  the  patient.  The  temperature  of  the  water  should  be  about 
95°  F.  It  is  best  carried  out  in  a  long  bath-tub  at  the  bed  side  with  a 
comfortable  hammock  arrangement  attached  to  the  sides  of  the  tub  to 
suspend  the  patient  and  facilitate  moving  him. 

Burning  and  Itching.  This  may  be  delayed  by  prolonged  warm 
baths  at  95°  F.  or  the  efficacy  of  the  baths  may  be  enhanced  by  the 
addition  of  carbonate  of  soda,  2  to  10  ounces  of  soda  to  a  bath-tub  of 
water  (30  gallons). 

As  the  itching  and  burning  is  most  intense  in  the  face  and  hands, 
cold  compresses  may  be  applied  to  them  with  comfort.  Hot  compresses, 
especially  to  the  extremities,  are  sometimes  found  more  grateful. 

Ruhrah  has  mentioned  the  efficacy  of  alum  solutions  1  per  cent, 
to  2  per  cent.,  or  baths  in  a  1  to  1,000  solution  (1  pound  of  the  alum  in  a 
bath-tub  of  500  liters). 

When  watery  solutions  are  not  applied  oily  substances  find  favor, 
for  they  both  alleviate  the  discomforts  and  keep  the  pustules  soft  and 
facilitate  their  discharge.  Opening  these  pustules  to  relieve  the  patient 
of  the  effects  of  absorption  from  them  appeals  to  me.  Of  course,  all 
applications  must  be  frequently  changed,  especially  in  the  pustular 
stage,  as  the  dressings  soon  become  drenched  with  discharges. 

Ointments  are  especially  applicable  when  the  crusts  begin  to  form. 

Simple  vaseline  or  sweet  oil  may  be  applied  to  the  skin  or  to  dress- 
ings, but  the  itching  is  more  quickly  ameliorated  if  3  per  cent,  to  5  per 
cent,  carbolic  (phenol)  is  added  to  the  one  or  the  other. 

Some  clinicians  advocate  glycerin  one  part  to  two  of  water  as  an 
excellent  application. 

The  itching  is  sometimes  intolerable;  yielding  to  it  lacerates  the  skin 
and  invites  such  secondary  infections  as  abscesses  and  erysipelas.  In 
children  mechanical  restraint  may  be  necessary  to  prevent  the  scratch- 
ing, such  as  splints  at  the  elbows  and  thick  "boxing-glove"  like  ban- 
dages to  the  hands.  Innumerable  applications  have  been  advocated, 
their  very  number  declaring  the  difficulty  of  the  problem.  Hubbard 
uses  on  the  face  white  precipitate  ointment  (ointment  of  ammoniated 
mercury)  linen  mask.  Appreciating  the  possibility  of  absorption  he 
changes  occasionally  to  ordinary  zinc  oxide  ointment.  He  also  uses 
cold  watery  solutions  of  glycerin  3i  to  5i  (4-30  c.c.)  applied  on  absorb- 
ent cotton. 

Ruhrah  advocates  spraying  with  alcohol  to  relieve  the  itching  and 
sometimes  adds  1/2  per  cent,  to  1  per  cent,  menthol  to  this.  He  further 


SMALL  POX  613 

speaks  of  the  value  of  spraying  with  carbolic  acid  (phenol)  in  water 
solution  1  to  40. 

Schamberg  advocates  warmly  the  use  of  undiluted  tincture  of  iodine. 
He  begins  this  early  and  applies  it  to  the  face  once  or  twice  a  day,  if  the 
skin  is  not  too  sensitive.  In  some  cases  a  dilution  of  one-half  may  be 
used.  He  claims  not  only  increased  comfort  under  the  application  but 
a  modification  in  the  severity  of  the  eruption,  a  decrease  in  the  secondary 
infections  and  a  relief  from  offensive  odors.  (Practical  Treatment, 
Musser  and  Kelly.) 

If  the  face  becomes  dry  and  uncomfortable  under  the  treatment,  they 
apply  such  ointments  as  cold  cream.  Powders,  too,  have  been  used  to 
allay  the  itching.  Hubbard  (Hare's  Modern  Treatment)  speaks  highly  of 
one  made  of  equal  parts  of  boric  acid,  lycopodium,  corn-starch  and 
subgallate  of  bismuth.  He  applies  this  freely. 

The  offensive  odor  demands  the  physician's  attention. 

The  application  of  iodine  lessens  this. 

Schamberg  uses  iodofonn  2  parts,  boric  acid  10  parts,  and  talcum 
28  parts,  dusting  it  on  freely  after  a  bath. 

Aristol  (thymol  iodide)  may  be  used  instead  of  iodoform. 

To  Separate  the  Scabs.  Warm  sponge  or  tub  baths  facilitate 
the  separation  as  do  ointments  or  plain  vaseline. 

Care  of  the  Skin.  When  the  scabs  fall  off  the  skin  is  often  very 
tender  and  the  application  of  bland  and  sterile  toilet  powders  are 
grateful. 

Complications  such  as  furuncles,  abscesses  and  erysipelas  are  to 
be  treated  on  surgical  principles. 

If  the  head  is  shaved  at  the  beginning  of  the  disease  local  treatment 
of  the  eruption  on  the  scalp  will  be  greatly  facilitated. 

SYMPTOMATIC  TREATMENT 

Bowels.  When  first  seen  the  patient  should  be  given  an  initial 
catharsis  of  a  salt,  Rochelle,  Epsom,  or  Glauber's,  5ss.-i  (15-30  Gm.) 
in  three-fourths  glass  of  water  or  this  may  be  preceded  by  calomel  in 
divided  doses  gr.  1/4  (0.015  Gm.)  every  quarter  hour  for  six  doses  and 
two  or  three  hours  later  followed  by  the  salt. 

Later  the  bowels  should  be  moved  daily  or  every  other  day  by  enemata 
or  milder  salines,  such  as  Hunyadi  water,  milk  of  magnesia  or  one  of  the 
milder  salines  on  the  market. 

The  initial  stage,  which  marks  the  period  between  the  onset  and 
the  eruption,  usually  lasts  three  days.  It  is  rife  with  discomforts. 
The  onset  is  sudden  and  characterized  by  the  severity  of  pains  in  the 


614  TREATMENT  OF  ACUTE  INFECTIOUS  DISEASES 

head  and  back,  the  nervous  manifestations  of  the  toxemia  and  the 
fever. 

A  chill  usually  precedes  the  febrile  impulse,  but  requires  no  espe- 
cial consideration. 

The  fever  as  a  rule  is  maintained  during  the  initial  stage  at  about 
104°  F.  Such  a  degree  of  temperature  requires  no  interference.  Cool 
sponges,  however,  afford  the  patient  comfort. 

At  the  end  of  the  initial  stage  the  temperature  goes  down  to  normal  or 
.to  but  a  little  above  and  stays  down  until  the  stage  of  suppuration, 
when  it  goes  up  again. 

Excessive  high  temperatures  are  best  controlled  by  the  cold  pack 
or  prolonged  tepid  baths  at  95°  F. 

Headache  is  severe,  often  intense.  It  is  best  treated  by  the 
application  of  the  ice-bag  or  ice-coil. 

In  the  early  stages,  the  sthenic  period  of  the  fever,  small  doses  of 
phenacetin,  gr.  iii  to  gr.  v  (0.2-0.3  Gm.)  at  half-hour  intervals  for  three 
or  four  doses,  or  acetanilid  in  doses  of  gr.  iss.  to  gr.  ii  (0.10-0.120  Gm.) 
at  the  same  intervals  for  three  or  four  doses  may  be  safely  administered 
if  the  patient  has  not  cardiac  trouble.  Later  when  the  circulatory  ap- 
paratus has  felt  the  effects  of  the  toxins  of  the  disease  all  members  of  the 
coal-tar  series  should  be  avoided,  because  they  are  themselves  depressing. 

If  the  headaches  are  agonizing,  as  they  sometimes  are,  morphine 
may  be  imperative. 

The  same  drugs  may  be  used  to  relieve  the  backaches. 

Delirium,  may  occur  in  the  initial  stage,  but  is  more  common 
and  violent  in  the  suppurative  stage.  Fresh  air  and  the  ice-bag  applied 
to  the  head  may  give  some  measure  of  relief.  Prolonged  tepid  baths  are 
probably  more  efficacious. 

The  patients  must  be  very  carefully  guarded  lest  they  leave  the  bed 
and  do  themselves  harm.  Sometimes  mechanical  restraint  is  necessary. 
Sheets  drawn  fairly  snugly  and  firmly  secured  with  the  hands  held  under 
them  is  the  most  humane  method. 

If  delirium  becomes  so  decided  as  to  require  drugs,  morphine  is  the 
best  to  use,  in  doses  of  gr.  1/8  to  gr.  1/4  (0.008-0.015  Gm.)  of  the  sulphate 
hypodermically  and  this  may  have  to  be  given  three  times  in  the  day. 

Insomnia,  when  continued  night  after  night  becomes  a  serious  con- 
sideration, as  it  takes  a  mighty  toll  of  the  patient's  strength.  Well- 
ventilated  rooms,  good  nursing,  enough  water  to  drink,  all  conduce  to 
good  sleep.  The  ice-bag  is  a  help,  the  prolonged  warm  baths  contribute; 
but  in  spite  of  these  measures  drug  assistance  may  be  needed.  The  mild 
hypnotics  may  be  tried  at  first,  such  as  trional  gr.  x  to  gr.  xx  (0.65-1.30 
Gm.)  in  a  little  whiskey  or  in  powder  form,  washed  down  with  water,  or 


SMALL  POX  615 

in  a  little  warm  fluid  like  barley  water  or  milk;  or  chloralamid  may  be 
used,  gr.  xv  to  gr.  xxx  (1-2  Gm.)  in  whiskey  or  as  a  powder,  but  not  in 
warm  menstrua,  which  decompose  it. 

Either  of  these  drugs  may  be  repeated  in  the  same  dose  in  two  or  three 
hours  if  necessary. 

Bromides  in  doses  of  gr.  xxx  (2  Gm.)  may  be  given  in  the  early  evening 
or  this  dose  may  be  given  in  the  late  afternoon  and  repeated  in  the  even- 
ing. One  may  use  the  potassium  salt  or  the  mixed  or  "triple"  bromides, 
potassium,  sodium  and  ammonium  gr.  x  (0.65  Gm.)  each.  Administer 
in  water.  Chloral  in  gr.  x  doses  (0.65  Gm.)  may  be  tried  in  the  initial 
stage.  It  is  given  in  water  or  dilute  whiskey,  brandy  or  wine.  It  should 
not  be  given  later  when  the  centers  are  depressed. 

Too  many  attempts  with  these  milder  hypnotics  should  not  be  made 
to  the  sacrifice  of  the  patient's  strength,  but  morphine  should  be  used  in 
doses  of  gr.  1/8  to  gr.  1/4  (0.008-0.015  Gm.)  of  the  sulphate  hypoder- 
mically. 

Gastro-intestinal  symptoms  are  not  striking,  but  there  may  be  nausea 
and  vomiting  at  the  onset.  This  rarely  requires  treatment,  but  if  retch- 
ing continues  copious  draughts  of  warm  water  may  afford  relief  or 
small  doses  of  sodium  bicarbonate  gr.  x  to  gr.  xx  (0.65-1.20  Gm.)  or 
bismuth  subnitrate  gr.  x  to  gr.  xv  (0.65-1  Gm.). 

Respiratory  Symptoms.  There  may  be  some  laryngitis  and  this 
is  best  treated  by  inhalations  of  steam  or  medicated  steam,  using  com- 
pound tincture  of  benzoin,  oil  of  eucalyptus,  menthol  or  oil  of  pine;  but 
the  effort  to  inhale  and  the  discomfort  of  the  heat  attending  the  ad- 
ministration may  outweigh  the  benefit  accruing  to  their  use. 

Some  bronchial  involvement  is  common",  if  not  constant.  In  some 
cases  bronchopneumonia  may  occur.  For  the  treatment  of  these  con- 
ditions, so  far  as  the  eruption  will  permit,  see  Pneumonia,  Chap.  IX. 

Edema  of  the  glottis  is  a  much  severer  complication  and  should 
this  intervene  demands  intubation  (see  Diphtheria,  Chap.  XVIII)  or 
tracheotomy. 

Circulation.  When  evidences  of  a  failing  circulation  occur,  all  those 
measures  applicable  to  the  same  condition  in  other  acute  infections  are 
indicated.  For  detail,  see  Pneumonia,  Chap.  IX. 

Release  from  Quarantine.  Tlu>  should  be  permitted  only  when 
the  desquamation  is  completed,  and  this  occurs  last  in  the  thick  skin  of 
the  hands  and  feet.  Warm  baths  and  the  use  of  soap  facilitates  the 
desquamation.  Sweet  oil  or  vaseline  softens  the  dry  skin  and  hastens 
its  separation. 

Finally  the  patient  should  have  an  antiseptic  bath  of  1  to  10,000 
bichloride  after  a  thorough  soap  and  water  bath  and  a  shampoo. 


616  TREATMENT  OF  ACUTE  INFECTIOUS  DISEASES 

He  should  then  be  removed  to  a  clean  room  and  given  clean  clothes 
or  his  old  clothes  only  after  a  thorough  disinfection. 

Disinfection.  All  those  articles  that  have  come  in  contact  with 
the  patient  and  which  can  readily  be  spared  should  be  burned  when 
possible. 

Such  articles  as  clothing,  bedding,  mattresses,  carpets,  should  be 
disinfected  by  superheated  steam.  If  this  is  not  possible,  mattresses 
and  pillows  had  better  be  burned,  washable  bedding  boiled  thoroughly 
and  carpets  be  submitted  to  the  disinfecting  vapors  used  to  disinfect 
the  room. 

Formaldehyde  vapor  gas  is  the  best  as  it  is  not  injurious  to  any  fabric 
or  color.  Sulphur  dioxide  is  also  efficacious  but  its  injurious  effects  on 
metals  and  fabrics  must  be  remembered. 

For  details  of  disinfection,  see  Scarlet  Fever,  Chap.  XVII. 

The  dead  should  be  cremated  or  the  body  wrapped  in  sheets  saturated 
in  strong  antiseptics  and  buried  deep. 

VACCINATION 

That  after  more  than  one  hundred  years  of  the  beneficent  results 
of  vaccination  there  should  still  be  found  bitter  opponents  to  the  proce- 
dure, forces  us  to  accept  them  as  psychological  aberrants,  in  no  way 
amenable  to  facts  or  reason. 

Were  vaccination  universally  and  properly  carried  out  there  would 
be  no  small  pox  to  treat,  for  the  sporadic  case  and  the  poorly  protected 
community  that  furnish  the  factors  necessary  for  an  epidemic  would 
cease  to  exist  and  a  disease  whose  mortality  is  45  per  cent,  to  50  per  cent, 
and  in  individual  epidemics  even  higher  would  become  of  historic  in- 
terest only. 

Time  for  Vaccination.  The  first  vaccination  should  be  in  early 
infancy.  Before  the  fifth  month  the  reaction  is  less  than  later.  As  an 
accoucheur  it  was  my  custom  to  vaccinate  the  infant  before  the  lying-in 
period  was  completed.  The  results  were  most  satisfactory  both  with 
reference  to  the  character  of  the  "takes"  and  the  absence  of  constitu- 
tional reactions.  Revaccination  should  be  done  between  the  ages  of 
ten  and  fourteen  and  again  and  as  often  as  the  individual  is  directly 
exposed  or  an  epidemic  prevails  in  his  community,  unless  a  previous 
vaccination  dates  back  to  only  one  or  two  years. 

Vaccination  or  revaccination  is  to  be  insisted  on  in  every  member 
of  the  patient's  family  exposed  and  revaccination  should  be  practiced 
by  the  physician  and  nurse  on  the  occasion  of  every  small  pox  patient 
seen,  unless  the  interval  is  less  than  a  year.  A  failure  to  "take"  on 


SMALL  POX  617 

revaccination  may  be  due  to  many  other  causes  than  lack  of  suscepti- 
bility, so  that  in  case  of  marked  exposure,  a  surety  of  technique  and 
freshness  and  activity  of  virus  must  be  had  and  a  repetition  of 
the  inoculation  is  the  better  part  of  wisdom. 

The  average  period  of  protection  is  usually  accepted  as  seven  years, 
but  this  period  must  not  be  accepted  as  an  excuse  for  not  revaccinating 
after  exposure. 

All  persons  who  have  been  exposed  should  be  revaccinated,  nor  should 
the  length  of  time  after  exposure  enter  into  the  question  of  whether  the 
exposed  individual  should  be  revaccinated  or  not,  for  even  if  the  protec- 
tion afforded  be  not  complete  it  may  be  relatively  so.  Early  in  the 
incubation  period  a  vaccination  will  prevent  the  disease.  In  these  cases 
the  typical  vaccination  pustule  has  time  to  develop  before  the  febrile 
period  is  due.  In  the  middle  of  the  incubation  period  vaccination  will 
serve  to  modify  the  severity  of  the  disease;  late  it  will  have  no  effect. 

Previous  vaccinations  enhance  the  efficiency  of  the  last  done  dur- 
ing the  incubation  period.  This  period  is  ten  to  twelve  days. 

Technique.  The  virus  must  be  active  and  secured  from  recognized 
sources. 

Virus  furnished  in  capillary  tubes,  each  a  single  inoculation,  is  pref- 
erable to  the  dried  virus  on  points.  If  kept,  it  must  be  kept  cold,  as 
high  temperature  destroys  it  or  lessens  its  strength. 

The  site  of  inoculation  is  best  rendered  clean  by  soap  and  water, 
best  by  green  soap  and  boiled  water,  and  this  followed  by  alcohol.  When 
dried  it  is  ready  for  the  inoculation.  The  site  preferred  is  the  arm, 
usually  the  left,  at  the  insertion  of  the  deltoid.  The  resulting  scar, 
which  in  a  woman  is  deemed  undesirable  at  this  site,  may  lead  one  to 
choose  the  leg.  The  place  commonly  chosen  is  on  the  outer  aspect  of 
the  leg  (not  thigh)  just  below  the  head  of  the  fibula. 

The  inoculation.  A  slight  wound  is  made  at  the  chosen  site.  Some 
prefer  scraping  with  the  edge  of  a  scalpel,  others  a  scarification  by 
cross-hatching,  and  others  incisions.  Incisions  are  insisted  on  in  Ger- 
many and  recommended  in  England.  They  are  made  with  the  edge  of  a 
scalpel  or  point  of  a  needle  in  Germany,  1  cm.  long  and  2  cm.  apart, 
4  in  number. 

I  prefer  a  small  cross-hatch  of  about  1/8  inch  square  made  with  a 
needle  sterilized  in  a  flame.  If  there  has  been  exposure  three  or  four 
of  these  3/4  inch  apart. 

Blood  should  not  be  drawn  by  any  method  to  a  greater  extent  than  to 
produce  bloody  serum.  The  virus  is  then  applied  to  the  abrasion  and 
rubbed  gently  in  with  a  sterile  needle,  using  the  eye-end  or  a  sterile 
wooden  toothpick,  using  the  blunt  end.  The  serum  and  virus  is  then 


618  TREATMENT  OF  ACUTE  INFECTIOUS  DISEASES 

allowed  to  dry  in  the  air.  The  only  protection  necessary  is  several  layers 
of  clean  gauze  sewed  into  the  sleeve  of  the  undervest,  drawers-leg  or 
stocking  over  the  site  of  the  inoculation.  Once  thoroughly  dry,  a  folded 
clean  handkerchief  may  be  used.  If  the  child  cannot  be  trusted  to  avoid 
scratching,  this  gauze  should  be  secured  to  the  part  by  adhesive  strap- 
ping, but  should  be  loose  over  the  inoculation. 

Shields,  pads  and  other  protective  contrivances  do  very  much  more 
harm  than  good. 

After  the  first  day  bathing,  including  the  site  of  the  inoculation,  need 
not.be  avoided. 

If  the  vesicle  ruptures  it  is  to  be  cleansed  with  saturated  boric  acid 
solution  and  10  per  cent,  boric  acid  ointment  (made  with  vaseline)  may 
be  applied. 

If  it  becomes  infected  it  is  to  be  treated  exactly  like  any  infected 
wound,  on  surgical  principles. 

If  the  vaccination  "takes,"  on  the  third  or  fourth  day  a  papule  ap- 
pears, and  on  the  fourth  or  fifth  day  a  vesicle  with  umbilication,  showing 
an  infiltration. 

The  vesicle  becomes  mature  on  the  seventh,  shows  the  pustule  on  the 
eighth  with  a  second  umbilication.  An  areola  has  formed  about  the 
developing  vesicle  and  on  the  ninth  day  this  begins  to  fade,  on  the 
eleventh  or  twelfth  day  the  scab  forms  and  slowly  separates  in  the  third 
or  fourth  week,  leaving  a  pit  which  heals  with  a  scar  showing  the  char- 
acteristic pits  or  foveations  which  are  the  sign  of  a  successful  vaccination. 

General  Symptoms.  With  the  appearance  of  the  vesicle  and 
during  its  development  there  may  be,  but  not  necessarily,  a  febrile 
reaction  with  attendant  discomforts  such  as  headache,  backache,  etc., 
simulating  a  mild  attack  of  grip.  The  part  inoculated  may  itch  or  burn 
or  a  considerable  inflammatory  reaction  with  a  resulting  sore  arm  may 
ensue. 

The  regional  lymph  glands  are  usually  swollen  and  often  tender. 

Immunity  is  established  about  the  time  of  the  pustule  formation, 
on  the  eighth  day. 

Complications  of  Vaccinations.  These  are  percentually  small,  but 
in  one  or  other  form  must  be  met  by  every  active  practitioner.  The 
most  common  result  from  infection  of  the  wound  by  pyogenic  organisms. 

All  too  frequently  one  sees  deep  and  broad  ulcerations;  less  com- 
monly, abscesses,  cellulitis,  lymphangitis,  phlebitis,  suppurating  glands, 
gangrene,  erysipelas  and  pyaemia.  As  a  less  serious  complication  we  see 
occasionally  an  impetigo  contagiosa.  When  one  considers  the  careless 
and  often  filthy  habits  of  many  who  are  compulsorily  vaccinated,  the 
numbers  of  serious  infections  seem  incredibly  small. 


SMALL  POX  619 

These  complications  are  nearly  all  surgical  problems  and  to  be  treated 
on  surgical  principles. 

Another  serious  but  fortunately  rare  complication,  which  from  its 
dramatic  course  always  attracts  public  attention,  is  Tetanus. 

It  is  true  that  this  unfortunate  infection,  which  has  been  traced 
more  than  once  to  the  virus  (and  then  several  such  cases,  directly  trace- 
able to  the  same  supply  of  virus),  does  occur;  but  I  am  convinced  that 
in  the  vast  majority  of  instances  and  in  all  sporadic  cases  it  is  due  to 
infection  of  the  wound  by  the  patient. 

A  case  seen  recently  by  me  in  consultation  was  such  an  one,  for  no 
other  case  from  this  virus  had  been  reported  to  the  Board  of  Health 
and  the  technique  of  the  practitioner  was  irreproachable.  The  child 
was  saved  by  prompt  intraspinal  administration  of  tetanus  antitoxin. 
(See  Tetanus,  Chap.  XL.) 

Generalized  vaccinia  occasionally  occurs  as  a  result  of  vaccination. 

It  appears  usually  during  the  development  of  the  vesicle  to  a  pustule, 
comes  out  in  crops  and  may  last  some  time,  in  rare  instances  three 
to  four  weeks. 

The  same  thing  may  occur  as  the  result  of  auto-inoculation.  This 
is  due  to  conveyance  of  the  virus  from  the  ruptured  pustule  to  other 
slight  abrasions  on  the  body,  most  commonly  by  scratching. 

Contraindications.  During  illness  or  if  recently  exposed  to  the 
exanthemata;  if  there  is  any  suppurative  process  in  the  body  or  of 
the  skin;  in  illy  nourished  infants  or  in  adults  suffering  from  severe 
constitutional  or  organic  disease.  It  is  contraindicated  in  bleeders 
for  obvious  reasons. 

It  is  better  not  to  vaccinate  during  menstruation,  unless  the  need 
is  urgent. 

Revaccination.  The  course  is  not  always  the  same  as  in  the  first 
vaccination. 

It  may  be  in  those  cases  in  whom  the  immunity  has  disappeared; 
but  those  in  whom  a  partial  immunity  persists,  an  anaphylactic  state 
or  "allergic",  show  what  the  students  of  anaphylaxis  entitle  "an  ac- 
celerated reaction";  that  is,  a  shortened  incubation  period  and  pustule 
formation  (the  sixth  day);  or  "an  immediate  reaction"  with  an  incu- 
bation period  of  less  than  twenty-four  hours  and  the  formation  of  a 
papule  or  erythematous  halo  about  the  site  of  the  inoculation,  the 
equivalent  of  the  now  familiar  Von  Pirquet's  tubercular  reaction. 

Conviction,  vision,  courage,  persistency  in  advocacy,  were  all  needed 
to  establish  this  amazing  contribution  to  human  welfare  one  hundred 
years  before  the  birth  of  immunilogical  studies  and  all  these  were  found 
in  Jenner. 


620  TREATMENT  OF  ACUTE  INFECTIOUS  DISEASES 

SUMMARY 

Isolation. 

Hospital  treatment  preferred. 
Home  treatment. 

Room. 

(For  choice  andttreatment  of  room,  see  Pneumonia  and  Scarlet  Fever. 

Chaps.  IX,  XVII.) 
Disinfection   during  illness   of  discharges,    clothes,   objects.      (See 

Typhoid  Fever,  Chap.  XIV.) 

Nurses. 

Should  be  revaccinated. 
Isolated  from  rest  of  household. 
(See  Scarlet  Fever,  Chap.  XVII.) 

Treatment  of  other  members  of  the  family  or  exposed  individuals. 
Vaccinate  with  a  virus  from  more  than  one  source. 
Quarantine  if  possible. 
Release  when  vaccination  is  successful. 

If  vaccination  does  not  "take",  quarantine  or  keep  under  closest 
observation  sixteen  to  eighteen  days. 

Physicians. 

Revaccinate. 

Make  case  last  call  of  day  if  possible. 

Stay  only  long  enough  to  fulfil  duties. 

Do  not  call  on  a  susceptible  person  at  once,  but  keep  in  open  air  for 

a  time. 
(For  rules  of  visit  and  disinfection  on  leaving  see  Scarlet  Fever, 

Chap.  XVII.) 

Bed. 

(For  choice  and  technique  of  making  bed,  see  Chap.  IX.) 

Diet. 

Don't  force  during  early  stages  when  there  is  much  anorexia;  milk, 
milk  preparations,  cereal  waters,  cereal  foods  (infant  foods), 
broths  fortified  with  cereals  or  farinaceous  flours,  egg  albumin. 

Later,  try  to  approximate  food  needs.  (See  Typhoid  Fever,  Chap. 
XIV.)  Condition  of  mouth  makes  it  difficult. 

Water,  offer  freely,  every  hour. 
Fruit  drinks,  lemonade,  orangeade,  etc.,  fortified  with  sugar. 

Alkaline  waters. 

Care  of  the  body. 
Mouth. 

Pre-emptive  period. 

Rinse  after  each  feeding  with  water,  then  with 


SMALL  POX  621 

Boric  acid  solution  2  per  cent,  to  4  per  cent,  or 

Dobell's  solution  half  to  quarter  strength. 

Teeth  cleansed  with  soft  toothbrush  and  good  paste  or  with  cot- 
ton swabs  on  wooden  toothpicks,  wet  with  above  solution. 
Free  interstices  of  teeth  and  dead  spaces  between  cheeks  and  gums 

from  food. 
Soften  coating  on  tongue  with  half  strength  official  peroxide  of 

hydrogen.    Scrape  with  edge  of  whalebone. 
Eruptive  period. 

Cannot  use  toothbrush  or  whalebone. 

Irrigations  of  above  solutions. 

When  mouth  is  foul. 

Permanganate  of  potash  solution,  claret  colored  (1-4,000). 
Chlorate  of  potash  gargles  1  per  cent,  or  less. 
Ulcers. 

Touch  with  silver  nitrate  solution  5  per  cent,  to  10  per  cent. 

Nose. 

Dried  secretions  softened  with  sweet  oil  or  vaseline. 
Cleansed  with  above  solutions  applied  with  swabs  on  toothpicks 

or  as 
Sprays. 
Eyes. 

Cleansed  with  2  per  cent,  to  4  per  cent,  boric  acid  solution. 
When  closed  with  edema 

Gentle  irrigation  of  conjunctival  sacks  with  warm  boric  acid 
solutions  2  per  cent,  to  4  per  cent. 

Cold  compresses  of  boric  acid  solution,  frequent  and  prolonged. 

Prevent  lids  sticking  by  applying  vaseline  to  edges  or  1  part  of 

yellow  oxide  of  mercury  to  60  of  vaseline. 
Severe  conjunctivitis. 

Five  per  cent,  to  20  per  cent,  argyrol  solution  once  or  twice  a 

day. 
Corneal  ulcerations. 

Apply  atropine  sulphate  solution  1  per  cent. 
Skin. 

Pre-emptive  period. 

Sponge  baths  of  soap  and  warm  water. 
Eruptive  period. 

Prolonged  warm  baths,  at  95°  F.  in  tub. 
Burning  and  itching. 

Warm  baths  at  95°  F. 

Bicarbonate  of  soda  may  be  added  to  the  bath. 

Cold  compresses. 

Alum  solutions  1  per  cent,  to  2  per  cent. 

Alum  baths  1  to  1,000  solution. 

Simple  vaseline. 

Sweet  oil. 

Three  per  cent,  to  5  per  cent,  phenol  in  oil  or  vaseline. 

Glycerin  33  per  cent,  solution  in  water. 


622  TREATMENT  OF  ACUTE  INFECTIOUS  DISEASES 

To  prevent  scratching  in  children.          ^ 

Mechanical  appliances. 

Splints  to  elbows. 

Bandages  to  hands. 
(For  other  appliances,  see  text.) 

Cold  cream. 
Powders. 

Sterile  toilet  powders. 


Boric  Acid, 
Lycopodium, 
Corn  Starch. 
Subgallate  of  Bismuth,  equal  parts. 
Offensive  odors. 


Hubbard. 


lodoform,      2  parts,  1 
Boric  Acid,  10  parts,  [  Schamberg. 
Talcum,       28  parts.  J 
Aristol  (Thymol  Iodide). 
To  separate  scabs. 
Warm  baths. 
Vaseline. 

Apply  sterile  toilet  powders  to  tender  skin  after  scabs  fall  off. 
Furuncles,  ^ 

Abscesses,    I  Apply  surgical  principles. 
Erysipelas,  j 

Symptomatic  treatment. 
Bowels. 

Calomel,  gr.  1/4  (0.015  Gm.)  every  quarter  hour  for  four  doses,  then 

in  two  hours, 
A  salt,  Epsom,  Rochelle  or  Glauber's  5ss.  to  i  (15-30  Gm.)  or  a  salt 

alone. 
Later. 

Milder  salines. 
Milk  of  magnesia. 
Citrate  of  magnesia. 
Hunyadi  water  or 
Enemata. 
Fever. 

Cool  sponges. 

Prolonged  warm  baths  at  95°  F. 

Excessive  fever. 

Cold  packs. 
Headache. 

Ice-bag  or  ice-coil. 
Early  stages. 

Phenacetin  gr.  iii  to  gr.  v  (0.20-0.30  Gm.)  every  half  hour  for 
three  to  four  doses. 


SMALL  POX  623 

Acetanilid,  gr.  iss.  to  gr.  ii  (0.10-0.12  Gm.)  at  same  intervals. 

Do  not  use  these  when  circulation  is  depressed. 
When  very  severe. 

Morphine  sulphate,  gr.  1/12  to  gr.  1/4  (0.005-0.015  Gm.). 
Backache. 

Same  drugs  as  for  headache. 
Delirium. 
Fresh  air. 
Ice-bag. 

Prolonged  warm  baths  at  95°  F. 
Mechanical  restraint,  best  with  tightly  drawn  sheets. 
Morphine  sulphate  hypodermically,  gr.  1/8  to  gr.  1/4  (0.008-0.015 

Gm.). 
Insomnia. 
Air. 

Ice-bag  to  head. 
Prolonged  warm  baths  at  95°  F. 
Trional  gr.  x  to  gr.  xx  (0.65-1.30  Gm.)  in  whiskey  or  in  powder. 

May  repeat  in  two  hours  if  needed. 
Chloralamid,  gr.  xv  to  gr.  xxx  (1-2  Gm.)  in  whiskey  or  in  powder. 

(Do  not  give  in  warm  drink.)    May  repeat  in  two  hours. 
Bromides,  gr.  xxx  in  evening  or  late  afternoon  and  repeat  in  even- 
ing, either  potassium  bromide  or  the  mixed,  "  triple,"  bromides 

of  potassium,  sodium  and  ammonium. 
Chloral,  gr.  x  (0.65  Gm.)  in  water,  whiskey  or  wine.    Do  not  use 

except  in  sthenic  period. 
Morphine  sulphate  hypodermically,  gr.  1/8  to  gr.  1/4  (0.008-0.015 

Gm.). 
Gastro-intestinal  symptoms.    Not  marked.    (See  text.) 

Respiratory  symptoms. 
Laryngitis. 

Inhalations  of  steam,  plain  or  medicated  with 
Compound  tincture  of  benzoin. 
Oil  of  eucalyptus. 

Oil  of  pine,  a  teaspoonful  or  two  in  the  hot  water,  or 
Menthol,  a  few  drops  of  saturated  alcoholic  solution  in  the 

hot  water  of  the  inhaler. 
Cold  compresses  to  neck. 

Bronchopneumonia. 

(See  Pneumonia,  Chap.  IX.) 

Edema  of  glottis. 

Intubation.    (See  Diphtheria,  Chap.  XVIII.) 
Tracheotomy. 

Circulation. 
(See  Pneumonia,  Chap.  IX.) 


624  TREATMENT  OF  ACUTE  INFECTIOUS  DISEASES 

Release  from  quarantine. 
When  desquamation  is  complete. 
Soap  and  water  bath  and  shampoo,  then 
Give  antiseptic  bath  of  1-10,000  bichloride  of  mercury. 
Remove  to  clean  room  and  put  on  clean  clothes. 

Disinfection. 

(See  Scarlet  Fever,  Chap.  XVII.) 


CHAPTER  XXVIII 

TYPHUS  FEVER 

THE  infecting  agent  in  typhus  fever  has  not  been  definitely  deter- 
mined, but  the  isolation  by  Plotz  of  New  York  of  a  Gram  positive 
pleomorphic  bacillus,  termed  bacillus  typhi  exanthematici  from  the 
blood  of  typhus  patients,  which  fixes  complement  in  the  serum  of  con- 
valescents from  the  disease,  makes  a  fair  claim  to  the  solution  of  the 
problem.  The  mode  of  conveyance  has  been  discovered,  thanks  to  the 
brilliant  work  of  Nicolle  and  Conseil,  Anderson  and  Goldberger,  Ricketts 
and  Wilder,  and  Gavino  and  Girard.  To  this  work  Ricketts  yielded  his 
life,  a  martyr. 

Again,  as  in  Malaria,  an  insect  plays  the  role  of  the  intermediary; 
this  time  the  louse,  Pediculus  vestimenti,  conveying  the  organism  by 
its  bite  from  the  infected  patient  to  a  susceptible  individual.  This 
constitutes  the  most  important  contribution  to  our  knowledge  of  the 
disease  ever  made  and  explains  many  observations  on  its  epidemicity; 
its  association  with  crowding,  wretchedness,  its  "short  striking  dis- 
tance/' its  prevalence  in  cold  climates  and  in  cold  season,  etc.  It  also 
renders  precise  efforts  to  prevent  its  spread  or  its  occurrence. 

In  these  latter  years  typhus  fever  had  been  considered  a  rarity  in 
the  Northern  States.  Recently  a  symptom  complex  which  had  many 
features  in  common  with  mild  typhus  fever  was  reported  by  Brill  of 
New  York.  A  considerable  number  of  these  cases  was  observed  in 
New  York,  Chicago  and  other  Northern  cities,  and,  for  a  time,  was 
considered  as  possibly  a  new  disease.  It  has  been  shown,  however, 
experimentally,  that  this  disease  is  identical  with  Mexican  (Tabardillo) 
and  European  Typhus  and  that  it  is  conveyed  by  the  same  means. 
The  incubation  period  of  typhus  lasts  as  a  rule  from  eight  to  twelve 
days;  exceptionally  as  short  as  four  or  as  long  as  fourteen.  The  invasion 
is  abrupt  and  the  duration  lasts  from  twelve  days  in  a  child  to  twenty- 
one  to  twenty-four  in  an  adult.  In  the  monkey  the  period  has  been 
observed  to  be  twelve  days. 

The  onset  of  the  disease  is  rapid,  characterized  by  the  sharp  rise  of 
temperature  which  reaches  its  maximum  on  the  second  or  third  day 
and  is  accompanied  by  very  severe  headache. 

The  temperature  is  sustained  throughout  the  disease  and  falls  by 
crisis  or  rapid  lysis  on  the  12th  to  14th  day.  The  characteristic  erup- 


626  TREATMENT  OF  ACUTE  INFECTIOUS  DISEASES 

tion  appears  on  the  third  to  the  fifth  day,  first  on  the  abdomen,  then  on 
the  chest,  the  shoulders,  the  back  and  the  extremities.  It  takes  two  to 
three  days  to  reach  its  full  development  and  there  are  no  second  crops. 
The  rash  suggests  measles,  but  later  becomes  petechial. 

Nervous  manifestations,  delirium  or  stupor  and  progressive  and 
severe  toxemia  are  the  striking  features  of  the  disease. 

Cardiac  weakness  may  appear  early,  but  is  much  more  pronounced 
with  the  appearance  of  the  rash.  The  blood  count  shows  a  slight  leu- 
cocytosis  of  about  10,000  and  a  polymorphonucleosis  of  80  per  cent,  to 
85  per  cent.  The  mortality  varies  in  different  epidemics  from  15  per 
cent,  to  60  per  cent.  The  sporadic  cases  as  seen  in  New  York  and  termed 
Brill's  Disease  are  relatively  benign,  the  mortality  not  reaching  more 
than  1  per  cent,  to  2  per  cent. 

TREATMENT 

Isolation.  The  knowledge  of  the  mode  of  conveyance  makes 
our  efforts  at  prevention  of  spread  more  successful  than  in  the  days 
when  it  was  supposed  to  be  conveyed  by  fomites  or  more  mysterious 
agents.  The  keynote  to  prevention  of  the  spread  lies  in  the  destruction 
of  the  body  louse.  The  patient  should  have  a  room  chosen  with  reference 
to  an  abundance  of  light  and  air  and  convenience  for  nursing. 

In  epidemics,  treatment  in  tents  is  preferable  to  the  more  poorly 
ventilated  wards. 

The  choice  of  the  bed  and  the  manner  of  its  preparation  should  be 
exactly  the  same  as  in  Typhoid.  (See  Typhoid  Fever,  Chap.  XIV.) 

As  soon  as  the  diagnosis  of  typhus  fever  is  made,  the  patient  should 
be  undressed  and  the  clothes  disinfected.  The  hah-  of  the  head,  pubes, 
axilla  and  chest  should  be  shaved  and  the  hair  burned. 

The  patient  is  then  scrubbed  with  soap  and  water  and  bathed  with 
dilute  (1  per  cent.)  carbolic  acid  or  50  per  cent,  alcohol.  After  the  skin 
is  dry  the  entire  body  is  sprayed  with  crude  petroleum  to  destroy  lice 
and  ova.  The  patient  is  put  to  bed  in  an  environment  free  from 
vermin. 

The  hair  on  the  pubes  and  in  the  axilla  or  in  hairy  individuals  that  on 
the  chest,  back  or  elsewhere  should  have  mercurial  ointment  applied  to 
these  parts. 

If  the  head  is  not  shaven  but  the  hah*  merely  clipped,  the  eggs  may  be 
loosened  from  the  hair  by  soaking  the  head  in  vinegar  overnight  and 
wiping  off  the  eggs  with  a  towel  wet  with  bichloride. 

It  must  be  remembered  that  it  is  the  body  louse  found  in  the  clothing 
that  is  the  transmitting  agent. 


TYPHUS  FEVER  627 

The  clothes  worn  by  the  patient  should  either  be  destroyed  by  burn- 
ing or  the  lice  killed  by  immersion  in  boiling  water.  Boiling  five  minutes 
is  said  to  kill  both  lice  and  eggs;  a  good  measure  of  time  increases  the 
assurance.  Live  steam  is  an  excellent  measure  applicable  to  extensive 
disinfection  as  practiced  in  delousing  plants  during  the  war. 

The  bed  where  the  patient  has  been  sleeping  should  be  scrubbed  with 
soap  and  water  and  treated  with  5  per  cent,  solution  of  carbolic  acid;  the 
mattress  and  the  blankets  subjected  to  steam,  the  sheets  and  spreads 
boiled;  the  room  is  disinfected  with  sulphur  dioxide  (use  5-8  pounds  per 
1,000  cubic  feet  and  leave  the  room  sealed  12-24  hours),  or  the  walls  and 
floors  may  be  sponged  thoroughly  with  crude  petroleum  and  after  12 
hours  scrubbed  with  soap  and  water. 

Nurses  and  attendants  should  wear  a  one-piece  garment  which  can 
be  tucked  into  high  boots,  rubber  gloves  and  close-fitting  head  gear  to 
prevent  pediculi  gaining  access  to  the  skin. 

Dr.  A.  C.  Burnham  of  the  American  Red  Cross  writes  us  of  the  follow- 
ing simple  device  for  disinfecting  clothes: 

"  In  an  ash  can  or  boiler  place  several  bricks,  add  sufficient  water  to 
half  cover  them.  Loosely  pack  clothes  in  a  wire  cage  (of  chicken  or  other 
similar  wire)  and  suspend  it  by  hooks  to  the  rim  of  the  can  so  that  it 
rests  on  the  bricks,  but  swings  free  of  the  water. 

Close  the  can  tightly  and  place  ten  to  fifteen  pounds  of  weight  on  the 
cover  so  that  the  steam  will  be  under  pressure.  Boil  the  clothes  for  one 
hour;  this  will  kill  all  the  lice  and  most  of  the  nits." 

Burnham  says  he  found  in  clothing  not  badly  infested  the  nits  could  be 
removed  by  carefully  pressing  with  a  very  hot  iron.  This  has  the  ad- 
vantage of  sparing  woolen  garments  from  no  inconsiderable  shrinkage. 
Of  course  the  garments  should  be  turned  inside  out  and  carefully  pressed 
along  the  seams. 

Furs  and  shoes,  if  dry,  may  be  disinfected  by  exposure  to  hot  air 
(60°  C.)  for  30  minutes. 

In  military  service  where  delousing  measures  are  carried  out  on  a 
large  scale,  treatises  on  military  practice  should  be  consulted. 

Care  of  the  Patient.  A  cleansing  bath  of  soap  and  warm  water 
should  be  given  daily.  Late  in  the  disease  particular  care  should  be  given 
to  prevent  the  formation  of  bed  sores  by  turning  the  patient  from  one 
side  to  the  other  frequently,  by  rubbing  the  points  of  pressure,  keeping 
the  parts  dry,  and,  when  the  parts  show  signs  of  pressure  by  persistent 
redness  or  bluish  discoloration,  using  rings  or  cushions  to  lift  the  part 
off  the  bed.  When  bed  sores  form,  if  superficial,  they  are  to  be  treated  by 
scrupulous  cleanliness  and  the  utilization  of  some  drying  powder  such  as 
stearate  of  zinc,  or  zinc  oxide,  talcum  and  starch  mixtures.  If  the  sores 


628  TREATMENT  OF  ACUTE  INFECTIOUS  DISEASES 

are  more  extensive  they  should  be  treated  on,  surgical  principles  and  the 
utilization  of  a  water  bed  or  air  bed  may  be  necessary. 

The  mouth  and  nose  should  be  treated  as  in  other,  infections 
by  keeping  them  clean  with  such  mild  antiseptics  as  boric  acid  solution 
2  per  cent,  to  4  per  cent,  or  some  mild  alkaline  solution  of  which  there  are 
many  on  the  market.  This  care  should  be  exercised  after  every  feeding 
and  particular  attention  should  be  given  to  the  removal  of  food  particles 
from  between  the  teeth  and  from  the  dead  spaces  in  the  mouth  between 
the  gums  and  teeth. 

In  the  severe  cases  the  mouth  becomes  very  dry,  the  tongue  heavily 
coated  and  sordes  appears  upon  the  teeth  and  lips. 

The  ease  with  which  otitis  and  parotitis  ensue  upon  a  foul  condition 
of  the  mouth  emphasize  the  importance  of  these  measures. 

The  treatment  will  be  found  detailed  in  the  article  on  Typhoid  Fever 
(Chap.  XIV). 

Diet.  Of  prime  importance  is  the  administration  of  an  abundance 
of  water;  a  sufficiency  of  water  diminishes  dryness  of  the  mouth, 
torpidity  of  the  bowel  and  heightens  the  efficiency  of  the  emunc- 
tories. 

The  mental  condition  of  the  patient  is  such  that  one  should  offer 
him  water  at  frequent  intervals,  at  least  hourly,  and  not  wait  for  expres- 
sion of  thirst  on  his  part.  All  the  water  should  be  given  that  the  patient 
will  willingly  take,  and  this  may  amount  to  three,  four  or  more  quarts 
a  day.  The  administration  of  food  is  determined  by  the  same  physio- 
logical necessity  as  in  any  continued  infection  (see  Diet  in  Acute  In- 
fectious Diseases,  Chap.  II),  and  the  rules  laid  down  for  diet  in  Typhoid 
Fever  hold  for  Typhus,  except  that  it  is  to  be  remembered  that  the 
urgency  for  a  high  caloric  diet  is  not  so  great  because  the  infection  runs 
a  shorter  course,  and  further,  that  the  degree  of  toxemia  as  a  rule  makes 
the  feeding  more  difficult  than  in  Typhoid  Fever. 

One  may  have  to  depend  almost  entirely  upon  liquids  or  semi-liquid 
foods,  such  as  are  set  forth  in  the  Typhoid  dietaries. 

Fever.  The  fever  is  usually  high  and  is  sustained  often  at  104°  F. 
to  105°  F.  throughout.  Except  in  rare  cases  of  hyperpyrexia  the  treat- 
ment directed  at  the  fever  is  really  directed  at  the  toxemia  and  its 
effects  upon  the  circulation  and  respiration ;  hence,  simple  antipyretics, 
such  as  the  coal  tars,  are  contraindicated;  first,  because  the  fever, 
per  se,  is  not  a  menace  to  the  patient,  but,  except  in  hyperpyrexia, 
is  rather  a  purposeful  reaction  of  the  body  harboring  toxic  material; 
secondly,  because  these  drugs  are  direct  and  potent  depressants  of 
the  circulation. 

The  antipyretic  measures,  however,  which  are  legitimate  are  those 


TYPHUS  FEVER  629 

which  are  at  the  same  time  stimulating  to  the  vital  functions  and  are 
used  because  of  this  latter  effect. 

They  are,  first,  the  use  of  cold  water,  and  one  may  have  recourse 
to  the  same  hydrotherapeutic  measures  as  in  Typhoid;  the  baths,  the 
slushes,  the  packs,  the  sponges,  with  the  same  indications  and  contra- 
indications as  in  Typhoid  (for  which  see  Typhoid  Fever,  Chap.  XIV) ; 
second,  open  air.  The  preparation  of  the  patient  and  his  bed  for  open 
air  treatment  is  identical  with  that  of  Pneumonia  (see  Pneumonia, 
Chap.  IX)  and,  as  in  Pneumonia,  the  delirium  of  the  patient  necessi- 
tates the  constant  presence  of  nurse  or  attendant  to  prevent  the  patient 
from  leaving  his  bed  and  doing  himself  some  injury. 

Circulation.  Except  in  fulminating  cases  the  circulation  does  not 
show  the  depressing  effects  of  the  toxin  until  the  second  week;  then 
the  rapid  heart,  the  low  blood  pressure  and  the  change  in  the  quality 
of  the  heart  sounds  bespeak  its  depressing  effects.  One  may  use  digitalis 
and  other  circulatory  stimulants  in  the  same  manner  as  described  for 
failing  circulation  in  pneumonia.  (See  Pneumonia.) 

It  must  be  remembered,  however,  that  more  potent  than  these 
drugs  are  the  effects  of  fresh  air  and  cold  water  as  described  under  Pneu- 
monia. 

Bowels.  Early  in  the  disease  the  intestine  should  be  thoroughly 
evacuated  by  the  use  of  Epsom  or  Rochelle  salt  in  doses  of  1/2  ounce  to 
1  ounce  (15-30  Gm.)  or  by  castor  oil  in  the  same  dose  or  by  calomel, 
grains  1  1/2  to  2  grains  (0.10-0.12  Gm.)  followed  in  four  hours  by  a  salt 
as  above. 

If  there  be  nausea  or  vomiting,  calomel  is  especially  indicated  but  in 
divided  doses,  1/4  grain  (0.015  Gm.)  every  quarter  hour  until  six  or  eight 
doses  are  taken.  Later  the  bowel  is  to  be  moved  by  an  enema.  In  this 
disease  constipation  and  meteorism  occur  not  infrequently  and  when 
the  circulation  is  embarrassed  or  the  lung  involved  the  latter  constitutes 
a  true  danger.  It  is  to  be  combated  in  the  same  manner  as  in  Typhoid. 
(See  Typhoid,  Chap.  XIV.) 

Nervous  Manifestations.  These  are  particularly  shown  in  the 
severe  headaches,  the  delirium  or  the  stupor.  The  headache  is  often 
intense  and  is  best  met  by  the  use  of  the  ice-cap;  in  the  more  violent 
headache  morphine  may  be  necessary. 

Delirium  and  Headache.  During  the  first  half  of  the  first  week 
the  mind  is  usually  clear;  then  delirium  or  stupor  intervenes;  the  delirium 
is  violent  and  hallucinations  of  a  terrifying  character  occur.  The  patient 
is  peculiarly  alert  and  requires  continual  watchfulness.  The  delirium 
increases  during  the  development  of  the  eruption.  It  is  to  be  treated  by 
the  application  of  the  ice-bag  to  the  head ;  in  milder  forms  by  bromides, 


630  TREATMENT  OF  ACUTE  INFECTIOUS  DISEASES 

15  to  30  grains  (1-2  Gm.)  three  or  four  times  a  day;  but  in  the  severe 
types  necessitates  the  use  of  morphine.  Lumbar  puncture  may  afford 
relief.  Instead  of  delirium  the  patient  may  go  into  stupor. and  coma; 
all  the  nervous  symptoms  are  likely  to  be  less  severe  or  are  ameliorated 
by  use  of  the  cold  bath  or  by  treatment  in  the  open  air,  but  in  the  latter 
case  some  restraint  and  constant  guarding  are  necessary. 

The  temperature  as  a  rule  subsides  by  crisis  or  rapid  lysis  occupying 
a  couple  of  days.  If  the  defervescence  occupies  a  much  longer  period 
one  should  think  of  the  possibilities  of  complications. 

Convalescence.  Convalescence  is  usually  rapid;  the  diet  is  in- 
creased and  the  patient  is  allowed  to  sit  up  in  bed,  then  in  the  chair, 
and  then  to  walk  around.  These  efforts  are  determined  by  the  patient's 
returning  strength  and  by  evidences  that  the  circulation  has  regained 
its  strength  as  shown  by  no  great  increase  in  pulse  rate  when  these  efforts 
are  made. 

Complications.  Laryngitis  is  fairly  common  and  may  be  treated 
by  inhalations  of  steam,  or  steam  medicated  with  compound  tincture 
of  benzoin,  oil  of  pine,  or  the  oil  of  eucalyptus,  a  teaspoonful  on  the  hot 
water  in  the  croup  kettle  or  a  substitute  for  it  in  the  shape  of  a  pitcher 
or  pail. 

Edema  of  the  larynx  sometimes  occurs  and  may  require  intu- 
bation, tracheotomy  or  scarification.  Bronchitis  and  Pneumonia  as 
well  as  Pleurisy  and  Empyema  can  take  place,  and  are  to  be  treated 
as  under  other  circumstances.  Frequently  turning  the  patient  lessens 
the  congestion  that  favors  the  onset  of  these  complications. 

Diarrhea.  While  constipation  is  the  rule,  diarrhea  sometimes 
is  seen.  Profoundly  toxic  patients  may  suffer  from  incontinence. 
Proper  care  of  the  bowels  from  the  start  renders  the  onset  less  probable; 
it  is  to  be  treated  by  Bismuth  subnitrate  in  30  grain  (2  Gm.)  doses 
every  two  hours,  or  by  small  doses  of  castor  oil,  10  minims  (0.60  c.c.) 
every  two  hours,  to  which  1  minim  (0.060  Gm.)  of  the  deodorized  tinc- 
ture of  opium  may  be  added  with  benefit.  In  either  case  it  is  well  to 
administer  a  large  dose  of  castor  oil,  y%  ounce  to  1  ounce  (15-30  c.c.), 
every  second  day. 

Parotitis.  This  complication  may  result  from  neglect  of  the  mouth. 
If  mild,  it  requires  no  treatment  or  the  application  of  an  ice-bag,  but 
if  suppuration  follows  it  must  be  treated  on  surgical  principles. 

Otitis  may  result  from  infection  from  the  mouth.  In  all  stupor- 
ous  patients  and  children  the  ears  should  be  daily  inspected.  The  con- 
dition is  to  be  treated  as  under  other  circumstances. 

In  some  epidemics  or  in  some  individual  cases,  the  disease  may  be 
so  mild  as  to  require  little  treatment  other  than  good  nursing;  again 


TYPHUS  FEVER  631 

it  may  be  fulminating  in  character  defying  all  effort,  and  resulting 
in  death  in  three  or  four  days.  Relapses  are  exceedingly  rare. 

Disinfection.  This  consists  in  the  destruction  of  the  parasite, 
the  louse,  either  by  burning  the  clothing  worn  by  the  patient  or  by 
disinfecting  it  as  described  above.  An  assurance  must  be  had  that 
the  patient's  body  is  freed  from  the  pediculi  and  the  room  must  be 
disinfected  by  burning  sulphur,  either  the  sticks  or  the  flowers,  5  pounds 
per  1000  cubic  feet,  leaving  the  room  closed  twelve  to  twenty-four  hours. 
Formaldehyde  is  of  doubtful  value  in  the  destruction  of  the  parasite. 

Prophylaxis  is  determined  by  a  knowledge  of  the  mode  of  convey- 
ance of  the  disease.  The  doctor  and  nurse  are  both  in  great  danger 
in  handling  fresh  patients  and  their  louse-burdened  clothes.  Protection 
by  gloves  and  gowns  and  caps  are  obvious;  prompt  disinfection  of  clothes 
and  patients  must  follow. 

Delousing  plants  in  infected  communities  should  be  of  great  assistance. 
Instruction  of  the  public  by  every  possible  means  should  be  used. 

It  has  been  suggested  that  crude  naphthalene  finely  powdered  be 
dusted  on  the  underclothing,  nightdress  and  sheets  in  infested  areas. 

SUMMARY 

Isolation. 

The  disease  is  conveyed  by  the  body  louse. 
Clothes  worn  by  patient  should  be  burned  or 
Boiled  or  pressed.    (See  text.) 
Hair  shaven  from  head,  pubes,  axillae. 

Burn  hair. 

Patient  scrubbed  with  soap  and  water,  sponged  with  75  per  cent, 
alcohol. 

Spray  entire  body  with  crude  petroleum. 

Apply  mercurial  ointment  to  the  axilla,  pubes. 

Put  to  bed  in  a  vermin-free  room  and  bed. 

Disinfect  former  bed,  mattress,  bedclothes  and  room. 
(See  text.) 

Room. 
Choose  with  reference  to  light,  air  and  convenience  for  nursing. 

Bed. 

(See  Typhoid  Fever,  Chap.  XIV.) 

Care  of  the  body. 
Daily  cleansing  bath. 

Try  to  prevent  bed-sores  by  turning  patient. 
Rubbing  the  point  of  pressure. 
Keeping  the  parts  dry. 
Using  rings  or  cushions. 


632  TREATMENT  OF  ACUTE  INFECTIOUS  DISEASES 

For  superficial  sores. 

Keep  sores  scrupulously  clean. 
Use  drying  powders  such  as 

S  tear  ate  of  zinc, 

Zinc  oxide, 

Talcum  and  starch  mixtures, 

Aristol. 
Deep  sores. 

Treat  on  surgical  principles. 
Use  water  bed  or  air  bed. 
Mouth  and  nose. 
Use  mild  antiseptics,  such  as  2  per  cent,  to  4  per  cent,  boric  acid 

solution,  especially  after  feeding. 
When  mouth  is  in  bad  condition,  treat  as  in  typhoid  fever.    (See 

Chap.  XIV.) 

Bowels. 
As  in  other  infectious  diseases.    (See  Typhoid  Fever,  Chap.  XIV.) 

Diet. 

Rules  for  feeding  and  details  for  feeding  may  be  borrowed  from 

Typhoid  Fever.    (See  Chap.  XIV.) 
Water  should  be  given  freely,  and,  if  patient  is  stuporous,  offered 

every  hour. 

Symptomatic  treatment. 
Fever. 

Hydrotherapy,  baths,  slushes,  packs  and  sponges  as  in  typhoid 
fever.    (See  Chap.  XIV.) 

Open  air. 
Just  as  in  Pneumonia.    (Chap.  IX.) 

Circulation. 
Just  as  in  Pneumonia.    (See  Chap.  IX.) 

Nervous  manifestations. 

Headache. 

Ice-cap  or  coil. 

Morphine  in  intense  headache. 

Delirium. 

Great  watchfulness. 
Ice-bag. 
Bromides,  gr.  xv  to  gr.  xxx  (1-2  Gm.)  in  water  three  or  four  times 

a  day. 
Morphine  sulphate,  gr.  1/12  to  gr.  1/4  (0.005-0.015  Gm.),  hypodermi- 

cally. 

Stupor  and  coma. 
Sp'enSreatment. 


TYPHUS  FEVER  633 

Convalescence. 

Usually  rapid. 
Increase  diet. 
(See  text.) 

Complications 

Laryngitis 
Medicated  steam,  using 

Compound  tincture  of  benzoin,  or 
Oil  of  pine,  or 
Oil  of  eucalyptus, 

3i  (4  c.c.)  in  a  croup  kettle,  or  pitcher  or  pail  with  paper  cone 
to  conduct  it. 

Edema  of  the  larynx. 
Intubation. 
Tracheotomy. 
Scarification. 

Bronchitis, 

Pneumonia, 

}•  As  under  other  circumstances. 
Pleurisy, 

Empyema. 

Diarrhea. 

Prevention — proper  care  of  bowel  from  beginning. 
Castor  oil  in  small  doses  or 
Bismuth  subnitrate  (See  text.) 
(See  summary  under  Bacillary  Dysentery,  Chap.  XVI.) 

Parotitis. 

Precautions,  proper  care  of  the  mouth. 

When  mild  no  treatment,  or  see  Parotitis  or  Mumps  (Chap.  XXIII). 

Suppurative — treat  on  surgical  principles. 

Disinfection. 

Destruction  of  body  louse. 

See  above  for  treatment  of  clothes  and  patient's  body. 
Room. 
Burn  sulphur,  5-8  pounds  per  1,000  cubic  feet. 

Prophylaxis. 
Doctors,  nurses  and  attendants  should  take  precautions  to  prevent 

infection. 

(See  text.) 

Debusing.    (See  text.) 
Use  of  crude  naphthalene  powder.    (See  text.) 


CHAPTER  XXIX 

PLAGUE 

PLAGUE  is  a  disease  due  to  an  infection  by  the  Bacillus  pestis  bu- 
bonica  isolated  by  Yersin  in  1894  and  often  accredited  to  Kitasato. 
This  organism  affects  peculiarly  the  lymphatic  glands,  the  swelling  of 
which  gives  the  characteristic  appearance  to  the  infected  and  the 
designation  "bubonic  plague." 

The  especial  carriers  of  the  organisms  are  rats  and  the  fleas  infest- 
ing them  afford  the  communication  between  the  rat  and  man. 

Rats,  however,  are  not  the  only  carriers;  for  example,  in  this  country 
the  California  ground  squirrels  have  been  shown  to  be  infected  and 
conveyance  may  be  made  through  other  insects  than  fleas,  and  through 
the  patient  by  pus,  vomitus,  sputum,  sweat  and  urine. 

While  the  bubonic  form  of  the  plague  is  the  common  one,  the  pre- 
dominance of  other  clinical  symptoms  may  warrant  other  designations, 
as  when  the  lungs  or  intestine  are  the  organs  especially  affected ;  hence, 
Pneumonic  or  Intestinal  Plague;  or,  when  the  toxemia  dominates  the 
picture  and  is  termed  Septicemic  or  Fulminating  Plague  or  the  opposite 
obtains  and  the  toxemia  and  local  manifestations  are  slight,  Pestis 
minor  or  Abortive  or  Ambulatory  Plague. 

So  rapid  and  wide-spread  is  the  plague,  so  frightful  its  consequences 
that  the  consideration  of  the  community  overshadows  that  of  the  in- 
dividual and  renders  the  chapter  on  prophylaxis  by  far  the  most  impor- 
tant in  the  story  of  Plague.  This  will  be  considered  presently. 

Therapy.  An  article  of  this  kind  can  deal  only  with  the  gen- 
eral principles  applicable  to  the  individual.  A  stricken  community 
demands  the  accumulated  fruits  of  experience  in  precautions,  details 
and  technique  that  can  only  be  afforded  by  more  exhaustive  treatises 
or  infinitely  better  yet  by  the  presence  and  control  of  men  of  actual 
experience  in  plague  epidemics. 

Isolation.  The  knowledge  that  each  individual  is  a  centre  of  infec- 
tion, through  his  secretions,  makes  his  isolation  imperative  and  that 
this  infection  may  be  conveyed  by  insects,  such  as  flies  and  ants  con- 
taminated by  these  secretions  or  through  the  bites  of  infected  insects,  as 
the  flea,  demands  screening  against  all  insects. 

Room.  The  room  should  be  well  aired  and  accessible  to  sunlight, 
as  darkness  and  dampness  favors  the  persistency  of  the  organism;  an 


PLAGUE  635 

ideal  is  a  temporary  shack  or  shelter  rather  than  in  an  old  and  rat- 
infested  house. 

The  bed  should  be  of  the  hospital  type;  of  iron,  hence,  readily  kept 
clean.  The  room  should  be  stripped  of  everything  except  the  absolutely 
necessary. 

Physician  and  nurse  should  wear  gowns,  caps  and  especially  rubber 
gloves  and  in  pneumonic  cases  protect  the  face  with  gauze  masks  such 
as  are  used  by  surgeons,  which  may  be  kept  moist  with  some  antiseptic 
solution,  and  glasses  to  protect  against  infection  coughed  into  their  faces. 
Doctors  and  nurses  should  take  advantage  of  such  protection  as  vaccine 
by  Haffkine's  or  Shiga's  method  will  afford. 

Sputa  should  be  received  on  gauze  or  rags  and  these  should  be  burned. 
Vomitus,  feces  and  urine  should  be  disinfected  and  clothes,  bed  linen, 
utensils  and  instruments  sterilized  as  in  Typhoid  Fever.  (See  Typhoid 
Fever,  Chap.  XIV.) 

Cleansing  baths,  the  care  of  mouth,  nose,  eyes,  skin  and  genitals  all 
demand  the  same  consideration  as  in  Typhoid  Fever.  (See  Chap.  XIV.) 

Diet.  Without  forcing  the  food  against  the  patient's  distaste,  an 
effort  should  be  made  to  approximate  food  needs,  however  remotely. 
Milk  and  milk  preparations,  cereals,  broths  thickened  with  cereals  or 
farinaceous  foods,  moistened  bread  or  toast,  eggs,  may  all  be  used. 
Water  should  be  given  abundantly. 

Bowels.  An  initial  cathartic  with  divided  doses  of  calomel,  gr. 
1/4  (0.015  Gm.)  every  quarter  hour  for  six  or  eight  doses,  followed  in 
two  hours  by  a  salt,  Rochelle,  Epsom,  or  Glauber's  3ss.-3i  (15-30  Gm.) 
may  be  given.  Later,  at  two-day  intervals  milder  salines  or  enemata 
may  be  used. 

Bladder.  It  must  not  be  forgotten  that  in  the  very  ill  urine  may 
be  retained  and,  if  lesser  measures  of  heat  or  cold  over  the  hypo- 
gastrium  fail,  catheterization,  with  all  precautions,  must  be  under- 
taken. 

Fever.  The  temperature  is  rarely  high  enough  to  demand  espe- 
cial consideration.  It  lasts,  as  a  rule,  from  a  week  to  ten  days  and  is 
very  irregular.  Sometimes,  however,  the  fever  lasts  for  several  weeks 
and  then  the  increased  caloric  needs  and  protein  destruction,  effects 
of  the  toxemia,  demand  particular  consideration  of  the  dietary. 

Rarely  excessive  fever  requires  antipyretic  treatment  which  is  best 
afforded  by  cold  water  in  the  shape  of  sponges  and  packs  or  if  the  buboes 
are  not  discharging  or  too  painful  as  tubs.  Antipyretic  drugs  are  de- 
pressing to  the  circulation  and  should  not  be  used. 

Circulation.  Good  nursing,  fresh  air,  food  and  cool  or  cold  spong- 
ing are  the  best  guarantees  of  a  good  circulation. 


636  TREATMENT  OF  ACUTE  INFECTIOUS  DISEASES 

If  drugs  are  to  be  used  the  indications  are,  the  same  as  in  the  other 
acute  infections.  (See  Pneumonia,  Chap.  IX.) 

Nervous  Symptoms.  Headache— is  best  controlled  by  the  ice-bag 
applied  to  the  head. 

Delirium  may  demand  restraint. 

Sleeplessness  is  to  be  met  by  the  milder  hypnotics  or  morphine  may 
be  needed  to  control  these  symptoms. 

Buboes.  As  the  swelling  increases  rapidly  the  pain  may  be  very 
great.  Perhaps  the  best  means  to  relieve  this  is  the  application  of  the 
ice-bag.  At  times  the  pain  may  be  so  severe  as  to  demand  morphine. 
Hot  fomentations  are  also  used  to  hasten  suppuration. 

When  fluctuation  occurs  incision  is  indicated  and  the  wound  treated 
on  surgical  principles. 

Diarrhea.  When  this  occurs  the  best  drug  to  use  is  bismuth  sub- 
nitrate.  Some  writers  consider  opium  contraindicated,  as  defeating 
the  effort  at  elimination  of  toxins. 

SPECIFIC    TREATMENT 

Serum.  An  anti-plague  serum  comparable  to  antidiphtheria  serum 
has  never  been  elaborated,  but,  especially,  the  Yersin-Roux  has  been 
tried  with  results  that  have  elicited  different  interpretations. 

I  quote  from  Wherry's  article  in  Forchheimer's  Therapeusis  of  Internal 
Disease. 

"The  discussion  concerning  the  value  of  the  Yersin-Roux  anti- 
plague  serum  has  apparently  been  satisfactorily  disposed  of  by  Chosky. 
His  series  includes  1,081  cases  treated  in  India  during  1905-1907.  In 
this  series  only  every  alternate  case  was  treated  with  the  serum,  the 
others  acting  as  controls.  Very  mild  cases  and  severely  septicemic 
and  moribund  cases  were  excluded. 

"The  general  mortality  was  reduced  to  49.6  per  cent.  In  cases 
treated  during  the  first  day  of  the  disease  the  mortality  was  30  per 
cent.;  this  increased  to  52  per  cent.,  among  those  treated  on  the 
second  day,  and  to  over  60  per  cent.,  among  those  treated  on  the  third 
day." 

Of  course  the  value  of  such  statistics  increases  with  their  number. 

As  the  general  mortality  of  the  Plague  in  India  at  this  time  was  89.9 
per  cent.,  the  reduction  under  the  serum  treatment  was  remarkable; 
but  in  addition  the  disease  was  shortened,  and  the  complications  les- 
sened. 

Early  administration  is  all  important  and  a  sufficiency  of  serum 
100-200-400  c.c.  should  be  given  and  early  repeated,  in  six  and  eight 


PLAGUE  637 

hours  and  again  at  weekly  intervals  as  the  condition  of  the  patient 
seems  to  demand. 

Intravenous  administration  is  always  to  be  preferred,  but  intra- 
muscular and  subcutaneous  are  often  combined  with  it. 

The  best  serum  at  present  seems  to  be  the  so-called  Yersin  serum, 
obtained  by  inoculating  horses  with  dead  organisms,  and  later  with 
increasing  quantities  of  living  virulent  organisms. 

Sequelae.  Aside  from  the  rarer  sequelae  prolonged  suppuration  of 
buboes  and  cardiac  weakness  in  convalescence  are  matters  of  moment. 

Convalescence.  Fresh  food  and  fresh  air  and  prolonged  rest  with 
watchfulness  over  the  state  of  the  circulation  are  the  essential 
measures. 

Disinfection.  This  should  be  thorough  and  effective  and  much  the 
same  measures  should  be  pursued  as  in  Scarlet  Fever.  (See  Scarlet 
Fever,  Chap.  XVII.) 

Prophylaxis.  Since  the  Indian  Commission  has  so  clearly  dem- 
onstrated the  role  of  the  rat  and  his  fleas  and  with  our  knowledge  of 
the  contagiousness  of  the  secretions  of  infected  men,  prophylactic  meas- 
ures can  be  directed  with  definite  ends  in  view. 

It  must  not  be  forgotten,  however,  that  while  rats  are  the  usual 
carriers,  other  animals  may  harbor  and  convey  the  infection  and  that 
in  our  own  country  the  California  ground  squirrel  especially  plays  this 
r61e. 

Jackson,  in  Hare's  Modern  Treatment,  sums  up  protective  measures 
for  the  community  in  this  way: 

"(1)  Active  warfare  against  rats  and  other  plague  affected  rodents, 
and  their  fleas; 

(2)  quarantine  applied  to  persons,  goods  and  animals; 

(3)  disinfection  of  cargoes  shipped  from  infected  ports; 

(4)  isolation  of  the  sick  and  proper  disposal  of  the  dead; 

(5)  international  notification  between  governments  of  the  occurrence 
of  plague  within  their  respective  territories; 

(6)  lastly,  but  perhaps  first  in  importance,  the  early  recognition  of 
the  presence  of  the  plague  and  rapid  diagnosis  in  individual  cases,  both 
dependent  upon  laboratory  workers." 

Warfare  against  the  fat  entails  the  building  of  rat-proof  structures 
in  ports;  the  prevention  of  ingress  and  egress  of  rats  when  ships  are  in 
port,  by  protection  of  hawsers  and  raising  of  planks  at  nightfall;  the 
proper  disposal  of  garbage  on  which  they  feed,  stopping  up  of  their  holes 
and  the  use  of  poisons  and  traps.  In  some  communities  cats  have  been 
employed  for  the  purpose,  though  not  entirely  a  safe  procedure  as  cats 
have  been  shown  to  develop  a  chronic  form.  The  presence  of  plague 


638  TREATMENT  OF  ACUTE  INFECTIOUS  DISEASES 

in  any  community  is  so  dire  a  threat  to  its  welfare,  the  possibility  of 
spread  in  the  community  so  great  that  ifc  immediately  becomes  a  public 
health  problem.  It  is  beyond  the  scope  of  a  handbook  of  this  type  to 
elaborate  upon  the  details  that  should  be  carried  out  by  public  health 
officers. 

Immunization.  Prophylactic  measures  may  be  applied  to  the  indi- 
vidual as  well.  Perhaps  the  most  efficacious  of  these  methods  is  the 
use  of  Haffkine's  prophylactic  inoculation.  It  consists  of  a  broth 
culture  of  bacillus  pestis  killed  by  heating  and  preserved  in  0.5  per  cent, 
carbolic  acid  and  injected  subcutaneously  in  amounts  of  0.5  to  4  c.c. 
repeated  in  larger  amounts  after  10  days.  The  reaction  is  often  quite 
severe. 

That  it  has  protective  power,  that  it  has  modified  both  the  incidence 
and  mortality  statistics  seem  now  to  have  been  proved  beyond  a 
doubt;  but  the  protection  is  not  absolute  even  though  immunity  seems 
to  be  marked  in  the  second  year  and  remains  in  a  slight  measure  in  some 
cases  for  five  years. 

A  modification  of  this  method  has  been  devised  by  Shiga  that  has 
the  advantage  of  quicker  preparation. 

If  given  within  a  few  hours  after  first  appearance  of  symptoms  it 
seems  to  have  some  curative  value. 


SUMMARY 
Isolation. 

Room. 

Well  aired  and  light  and  screened  from  flying  insects. 

Bed. 

Hospital  type  preferred. 

(For  technique  of  bed-making,  see  Typhoid  Fever,  Chap.  XIV.) 

Physicians  and  nurses. 

Wear  gowns  and  gloves  and  in  pneumonic  cases  wear  gauze  masks 

to  protect  face  against  the  patient's  cough. 
Prophylactic  vaccination  is  a  wise  precaution. 

Care  of  patient. 

Care  of  body  and  mouth,  nose,  eyes  and  genitals  as  in  any  acute  in- 
fectious disease.  (See  Typhoid  Fever,  Chap.  XIV.) 

Sputa  should  be  received  on  gauze  or  rags  and  burned. 

Vomitus,  feces,  urine  disinfected  and  clothes,  bed-linen,  utensils,  and 
instruments  sterilized  as  in  Typhoid  Fever.  (See  Chap.  XIV.) 


PLAGUE  639 

Diet. 

Do  not  force,  but  keep  in  mind  food  requirements.  (See  Chap.  II.) 
Milk,  milk  preparations,  cereals,  broths  thickened  with  cereals,  or 
farinaceous  foods,  moistened  bread  and  toast,  eggs. 

Water  should  be  given  freely. 

Bowels. 

Initial  cathartic. 
Calomel  in  divided  doses,  gr.  1/4  (0.015  Gm.)  every  quarter  hour 

for  six  or  eight  doses,  followed  in  two  hours  by 
Epsom  salt,  Rochelle  salt  or  Glauber's  salt,  gss.  to  5i  (15-30  Gm.) 

in  three-quarters  glass  of  water. 
Later. 

Milder  salines,  Hunyadi,  citrate  of  magnesia, 
Milk  of  magnesia  or  enemata  every  day. 

Retention  of  urine. 

Apply  heat  (hot  stupes)  or  cold  to  epigastrium.    If  these  fail  catheter- 
ize. 

Fever. 

Cold  sponges. 
Cold  packs. 
Cold  tubs. 

Circulation. 
(See  Pneumonia,  Chap.  IX.) 

Nervous  symptoms. 

Headache. 

Ice-bag  or  coil. 
Delirium. 

Restraint. 

Bromides,  gr.  xxx  (2  Gm.)  one  to  three  times  a  day. 

Morphine  hypodermically,  gr.  1/8-1/4  (0.008-0.015  Gm.). 

Hyoscine  hydrobromide,  gr.  1/150  (0.0004  Gm.). 
Sleeplessness. 

Bromides,  gr.  xxx  (2  Gm.)  in  water. 

Trional,  gr.  xv  (1  Gm.)  in  a  little  hot  water  or  whiskey  or  as  powder. 

Chloralamid,  gr.  xxx  (2  Gm.)  in  cold  water  or  whiskey  or  powder. 

Morphine  sulphate,  gr.  1/8-gr.  1/4  (0.008-0.015  Gm.). 

Buboes. 

Ice-bag. 

Morphine  sulphate  for  pain,  gr.  1/8-gr.  1/4  (0.008-0.015  Gm.). 

Hot  fomentations  to  hasten  suppuration. 

Incise  when  fluctuation  is  detected. 

Treat  on  surgical  principles. 


640  TREATMENT  OF  ACUTE  INFECTIOUS  DISEASES 

Diarrhea.     **-.  <* 

Bismuth  subnitrate,  gr.  xxx  (2  Gm.)  every  two  hours. 
Specific  treatment. 
(See  text.) 

Convalescence. 

Fresh  food. 
Fresh  air. 
Prompt  rest. 

Disinfection. 

(See  Scarlet  Fever,  Chap.  XVII.) 

Prophylaxis. 

(See  text.) 


CHAPTER  XXX 

DENGUE 

DANDY  FEVER.  BREAK  BONE  FEVER 

DENGUE,  essentially  a  tropical  disease,  is  confined  in  the  United 
States  to  the  Southern  tier  of  States.  Although  epidemics  have  been 
reported  as  far  north  as  Philadelphia. 

It  is  characterized  by  a  suddenness  of  onset,  and  a  rise  of  temperature 
with  severe  headache  and  a  striking  soreness  of  the  ocular  muscles, 
giving  rise  to  exquisite  pain  with  each  movement  of  the  eyes  and  pains 
all  over  the  body  that  closely  simulate  Influenza  but  with  especial 
localization  about  the  joints.  These  manifestations  of  intoxication 
last  two  to  five  days  and  are  followed  by  a  drop  in  temperature  often 
critical  and  accompanied  by  nose  bleed,  diarrhea  or  a  sweat  and  by  a 
remission  or  intermission  of  symptoms  of  twelve  hours  to  three  days, 
only  to  be  in  turn  followed  by  a  second  febrile  period  of  twenty-four 
to  thirty-six  hours.  An  erythema  may  accompany  the  first  period,  but 
the  characteristic  rash,  a  measles  like  eruption,  occurs  with  the  second 
access  of  fever  involving  hands  first,  spreading  to  arms  and  later  in- 
volving lower  extremities  and  trunk. 

The  blood  picture  is  a  leucopenia  and  relative  lymphocytosis. 

Profound  depression  of  spirits  accompanies  the  attack  and  the  con- 
valescence is  slow.  The  mortality  is,  however,  very  low. 

This  disease,  like  Malaria  and  Yellow  Fever,  is  in  all  probability 
transmitted  by  a  mosquito  (Culex  fatigans)  as  suggested  by  Graham 
of  Beirut,  though  as  yet  not  definitely  proved.  Some  workers  have 
suspected  the  stegomyia  to  be  the  host. 

Ashburn  and  Craig,  by  transmitting  the  disease  through  the  filtered 
blood  of  an  infected  person,  have  made  it  more  than  probable  than  the 
infecting  agent  belongs  to  the  group  of  ultramicroscopic  organisms. 

Therapy.  The  room  chosen  for  the  patient  should  be  as  cool 
and  airy  as  possible  or  better  yet  a  shaded  portico.  This  should  be 
screened  against  mosquitoes,  not  merely  as  a  protection  to  the  patient, 
but  as  a  protection  to  others  against  the  patient. 

The  bed  should  be  selected  with  a  view  to  comfort  as  the  bodily  pains 
are  so  great  as  to  make  any  position  one  of  discomfort.  (See  Rheumatic 
Fever,  Chap.  III.) 


642  TREATMENT  OF  ACUTE  INFECTIOUS  DISEASES 

Diet.  No  effort  should  be  made  to  forqe  food  during  the  period 
of  anorexia,  but  after  this  has  passed  milk  and  milk  preparations, 
cereals,  bread-stuffs  and  eggs,  cereal  broths  or  mutton  and  chicken 
broths  thickened  with  rice,  sago  or  barley  may  be  given  as  freely  as 
the  patient  will  accept  them,  while  during  the  long  and  tedious  con- 
valescence a  greater  variety  of  foods  temptingly  prepared  and  with  a 
consideration  of  the  patient's  caloric  needs  (see  Chap.  II)  should  be 
offered. 

Water  should  be  given  freely  throughout  the  febrile  periods  or  fruit 
juices  such  as  lemonade  or  orangeade  or  juice  of  grape  fruit. 

Bowels.  At  the  beginning  of  the  disease  the  bowels  should  be  freely 
moved  by  small  doses  of  calomel  and  salts,  e.  g.,  calomel  gr.  1/4  (0.015 
Gm.)  every  quarter  hour  for  six  to  eight  doses,  followed  by  5ss.  (15 
Gm.)  of  Epsom  or  Rochelle  salt,  and  every  second  day  a  mild  saline 
such  as  a  Seidlitz  powder  or  liquor  magnesii  citratis  gviii-xii  (240-360 
c.c.)  or  Hunyadi  water  may  be  administered. 

There  should  be  no  purging  as  the  condition  does  not  demand  it  and 
the  patient's  pains  and  discomforts  are  greatly  aggravated  thereby. 

Pains.  The  milder  anodynes  such  as  salicylates  in  gr.  x  (0.65 
Gm.)  doses  every  two  hours  or  phenacetin  (acetphenetidin)  gr.  iii  to  v 
(0.20-0.30  Gm.)  at  like  intervals  should  be  tried  first,  but  the  pains  are 
commonly  too  severe  to  yield  to  such  measures  and  one  should  have  re- 
course to  codeine  sulphate  or  phosphate  gr.  1/8  to  gr.  1/4  (0.008-0.015 
Gm.)  every  two  hours. 

At  times,  however,  the  headache  and  pain  is  so  acute  that  one  must 
use  morphine.  It  is  always  well  to  administer  this  drug  hypodermically 
rather  than  by  mouth  and  hi  the  smallest  doses  that  will  effect  the 
desired  results,  e.  g.,  a  beginning  dose  of  gr.  1/12  (0.005  Gm.). 

Local  Treatment  of  Pains.  An  ice-bag  to  the  head  may  miti- 
gate the  severity  of  the  headache  while  hot  cloths,  stupes  or  poultices 
may  give  relief  to  aching  back  and  joints. 

Fever.  No  effort  is  to  be  made  to  combat  the  fever  as  such,  as 
hyperpyrexia  is  very  rare,  but  measures  to  assuage  the  discomforts 
incident  upon  the  temperature  are  legitimate,  such  as  cool  sponges,  cool- 
ing drinks,  ice-bag  to  head. 

Tub  baths  add  too  much  to  the  patient's  pains  in  the  handling  to 
warrant  the  procedure  unless  hyperpyrexia  should  obtain. 

Circulation.  The  pulse  is  characteristically  slow  about  the  third 
day,  but  the  circulation  is  rarely  threatened.  Should  one  be  dealing 
with  a  poor  circulation  as  the  result  of  an  antecedent  condition,  the 
toxemia,  or  both,  the  indications  are  the  same  as  in  a  case  of  Pneumonia. 
(See  Pneumonia,  Chap.  IX.) 


DENGUE  643 

Nervous  Symptoms.  To  a  patient  suffering  from  Dengue  nothing 
is  more  gratifying  than  to  be  let  alone.  Quiet  and  good  nursing  and 
the  exclusion  of  visitors  are  of  first  importance  to  him. 

Insomnia  may  be  overcome  by  excluding  causes  of  nervous  irritation, 
by  the  artifices  of  efficient  nursing  and  lastly  by  drugs,  e.  g.,  sulphon- 
ethylmethane  (trional)  gr.  x  (0.65  Gm.)  in  the  early  evening  and  a 
repetition  of  the  dose  two  hours  later  if  needed  or  chloralamid  gr.  xxx 
(2  Gm.)  at  the  same  intervals. 

If  pain  is  the  cause  of  the  insomnia  codeine  phosphate  gr.  1/4  (0.015 
Gm.)  to  gr.  ss.  (0.030  Gm.),  may  be  used  to  assist  the  operation  of  the 
hypnotics,  but  in  cases  of  severe  pain  only  morphine,  as  already  specified, 
will  be  of  use.  With  this  the  other  hypnotics  are  unnecessary. 

Complications.  Occasionally  hemorrhages  may  occur  from  nose, 
stomach,  intestine  or  uterus.  Milder  hemorrhages  need  no  consideration, 
but  if  abundant  or  in  weakly  patients,  the  same  measures  are  to  be 
pursued  as  in  hemorrhages  from  other  causes.  (See  Typhoid  Fever, 
Chap.  XIV.) 

Convalescence.  It  is  curiously  protracted  for  an  infection  so  little 
fatal  and  is  to  be  hastened  by  a  sufficiency  of  food,  fresh  air,  quiet  and 
milder  tonics  such  as  mix  vomica  and  iron. 

Prophylaxis.  Accepting  the  theory  that  the  mosquito  is  the 
transmitting  agent  of  the  disease  efforts  should  be  made  to  rid  the 
community  of  the  pests  by  draining  swamps,  obliterating  or  treating 
with  oil  all  stagnant  water,  ponds,  pools,  cisterns,  and  removal  of  smaller 
containers,  such  as  buckets,  cans,  etc.,  together  with  screening  of 
dwellings  and  protection  of  the  exposed  parts  of  the  body  at  night- 
fall. Especially,  as  has  been  said,  the  infected  patient  should  be 
screened. 

Diagnosis.  Features  of  diagnostic  significance  are  the  two  febrile 
periods  separated  by  the  remission,  the  severity  of  the  pains,  the  slow 
pulse,  the  rash  of  the  second  period,  the  low  white  cell  and  polymor- 
phonuclear  count  (e.  g.,  3,200  whites  and  51  per  cent,  polymorphonu- 
clears)  and  the  protracted  convalescence. 

SUMMARY 
Room. 

Cool  and  well  ventilated. 

Shaded  and  screened  porch  or  veranda  desirable. 

Bed. 

Preferably  of  hospital  type,  with  woven  wire  springs,  firm  mattress 
and  smoothly  laid  sheets. 


644  TREATMENT  OF  ACUTE  INFECTIOUS  DISEASES 

Diet. 

Do  not  force  during  period  of  anorexia. 

Milk,  milk  preparations,   cereal  broths,  mutton  or  chicken  broth 
thickened  with  rice,  barley  or  other  cereal  or  farinaceous  flour. 

Water. 

Give  freely. 

Lemonade,  orangeade  and  other  diluted  fruit  juices.    May  add  sugar 
to  increase  food  value. 

Bowels. 

Calomel  and  salts  or  a  salt  alone. 

Calomel,  gr.  1/4  (0.015  Gm.)  every  quarter  hour  for  six  to  eight  doses. 

Epsom  salt  5ss.  (15  Gm.). 

Rochelle  salt  5ss.-i  (15-30  Gm.). 

Seidlitz  powder. 

Liquor  magnesii  citratis  5viii  to  xii  (240-360  Gm.). 

Hunyadi  water. 

Treatment  of  symptoms. 

Pain. 
Local. 

Hot  fomentations.    (See  Pneumonia,  Chap.  IX.) 
Poultice.    (See  Pneumonia,  Chap.  IX.) 
Sodium  salicylate  or  acetylsalicylic  acid  (Aspirin),  gr.  x  (0.60 

Gm.)  every  two  hours. 
Phenacetin  (acetphenetidin),  gr.  iii  to  gr.  v  (0.20-0.30  Gm.) 

every  two  hours. 
Codeine  sulphate  or  phosphate  gr.  1/8  to  gr.  1/4  (0.008-0.015 

Gm.)  every  two  hours. 

Morphine  sulphate  hypodermically,  gr.  1/12  to  gr.  1/8  (0.005- 
0.008  Gm.). 

Fever. 

Cool  sponges. 
Cool  drinks. 
Ice-bag  to  head. 

Circulation. 

Rarely  threatened. 

(If  stimulation  is  indicated,  see  Pneumonia,  Chap.  IX.) 

Nervous  symptoms. 
Marked  irritability  allayed  by  quiet  and  good  nursing. 

Insomnia. 

Sulphonethylmethane  (Trional),  gr.  x  (0.60  Gm.).    (May  repeat  in 

two  hours.) 
Chloralamid,  gr.  xx  (1.30  Gm.).    (May  repeat  in  two  hours.) 


DENGUE  645 

Codeine  phosphate,  gr.  1/8  to  gr.  1/4  (0.008-0.015  Gm.).    (If  due  to 

pain.) 
Morphine  sulphate,  gr.  1/12  to  gr.  1/8  (0.005-0.008  Gm.).    (If  due  to 

pain.) 

Complications. 

Hemorrhages.    (See  text.) 

(If  severe  same  as  Typhoid  Fever,  Chap.  XIV.) 

Convalescence. 

Protracted. 

Increase  food  intake. 
Fresh  air. 

Strychnine  sulphate,  gr.  1/60  to  gr.  1/20  (0.001-0.003  Gm.)  or 
Tincture  of  nux  vomica,  m.  x  to  m.  xv  (0.60-1  c.c.)  three  times  a  day. 
Iron  as  carbonate,  gr.  v  (0.30  Gm.)  three  times  a  day,  as  either 
B  laud's  pills,  or  Vallet's  mass. 

Prophylaxis. 

War  on  the  mosquito. 
(See  Malaria,  Chap.  XV.) 


CHAPTER  XXXI 

ASIATIC  CHOLERA 

ASIATIC  CHOLEKA  is  due  to  a  definite  organism,  the  so-called  "  comma 
bacillus"  discovered  by  Koch  in  1883  or  more  technically,  the  vibrio 
cholerse  asiaticse. 

It  is  conveyed  by  the  dejecta  of  the  infected  directly  or  through  the 
medium  of  water  and  always  gains  entrance  through  the  mouth. 

Its  toxin  and  endotoxin  acts  specifically  on  the  endothelium  of  the 

intestinal  canal  to  induce  those  alterations  in  function  that  constitute 

the  symptoms  of  the  disease,  namely,  excessive  diarrhea  with  collapse. 

The  mortality  is  high,  approximately  50  per  cent,  and  is  especially 

fatal  to  the  two  extremes  of  life. 

Isolation.  During  a  cholera  epidemic  the  slightest  diarrhea  should 
be  looked  upon  as  suspicious  and  the  patient  should  be  put  to  bed  and 
everything  be  done  to  conserve  his  strength  for  the  coming  struggle. 
The  problem  of  protection  against  infection  is  a  simple  one,  for  we 
know  the  source  of  the  infection  through  the  feces,  its  mode  of  convey- 
ance through  hands,  articles,  insects,  food  and  drink  contaminated 
by  the  dejecta  and  the  portal  of  entry  through  the  mouth. 

Isolation  prevents  the  ignorant  and  careless  who  come  into  contact 
with  the  patient  from  becoming  infected  and  spreading  the  disease  and 
prevents  added  infection  to  the  patient. 

Doctor  and  nurse  by  an  appreciation  of  the  facts  just  stated 
should,  by  use  of  gowns  and  gloves,  careful  cleansing  of  hands,  sterili- 
zations of  contaminated  objects,  and  destruction  by  fire  and  strong 
antiseptics  of  excreta,  protect  themselves  and  those  with  whom  they 
may  come  in  contact. 

Room.  During  an  epidemic,  of  course,  the  vast  majority  of  patients 
must  be  treated  in  hospitals,  camps,  etc.,  but  for  the  favored  few, 
who  may  be  treated  under  more  fortuitous  environments,  a  room, 
as  cool  and  as  well  ventilated  as  possible  should  be  chosen  and  this 
stripped  of  all  furnishings  and  hangings.  In  fact  the  source  and  mode 
of  conveyance  of  this  disease  is  so  like  typhoid  fever  that  the  details 
of  room,  bed,  sterilization  of  articles  used,  and  care  of  the  body  are 
identical  problems.  (See  Typhoid  Fever,  Chap.  XIV.) 

Diet.  At  first  it  is  well  to  eliminate  all  food-stuffs,  except  barley- 
water,  which  is  best  given  hot.  Later  other  farinaceous  gruels,  such 


ASIATIC  CHOLERA  647 

as  arrowroot  water,  rice  water,  whey,  and  then  cautiously  animal  broths 
thickened  with  farinaceous  foods,  and  then  milk. 

These  are  dietetic  measures  similar  to  those  we  use  in  the  gastro- 
enteritis of  infancy. 

Water  is  given  abundantly  in  small  quantities  freely  and  not  too  cold. 

Early  Treatment.  The  sooner  the  patient  is  put  to  bed  after 
the  looseness  of  the  bowels  appears  the  better.  He  should  be  covered 
warmly,  given  hot  drinks,  hot  weak  tea  or  lemonade  and  hot  stupes 
or  poultices  should  be  applied  to  the  abdomen. 

At  this  early  stage  opium  may  be  given,  but  later  in  the  disease  it  is 
a  dangerous  drug.  Indeed,  Stitt  advises  against  its  use  in  any  stage. 
One  may  give  m.  xx  (1.30  c.c.)  of  the  tincture  or  3ss.-3i  (15-30  c.c.) 
of  paregoric  or  in  smaller  and  frequent  doses,  as  m.  ii  (0.13  c.c.)  of  the 
tincture  or  gr.  ii  (0.13  Gm.)  of  Dover's  powders  or  3i  (4  c.c.)  of  pare- 
goric every  hour. 

Cathartics.  Rogers,  whose  masterly  article  in  Hare's  Modern  Treat- 
ment, should  be  read  with  attention  by  all  who  deal  with  this  disease, 
decries  the  use  of  cathartics  in  cholera  at  any  stage. 

Stage  of  Collapse.  Rogers'  treatment  while  not  specific,  is  deduced 
so  logically  from  what  we  know  of  physiological  requirements,  that  I 
shall  summarize  it  for  the  purposes  of  this  article  with  a  frank  confes- 
sion of  the  shortcomings  of  such  a  summary. 

Rogers  recognizing  the  obvious  fact  that  the  loss  of  fluids  from  the 
tissues  constitutes  the  danger  of  the  disease  and  that  its  replacement 
is  the  procedure  that  the  logic  of  the  situation  demands,  finds  his  success 
in  the  appieciation  of  the  significance  of  certain  minor  details. 

He  recognized  that  not  only  is  there  a  loss  of  fluid  by  the  tissues,  but 
also  a  marked  loss  of  salts,  both  of  which  should  be  replaced,  and  argued 
that  if  salts  were  introduced  in  hypertonic  solution  osmotic  currents 
could  be  determined  toward  the  blood  from  the  bowel  instead  of  away 
from  it  as  induced  by  the  toxic  agents.  Some  of  the  tropical  workers 
report  that  equally  good  results  have  been  obtained  from  the  use  of 
normal  saline  as  from  the  hypertonic  solution. 

The  condition  of  the  blood  Rogers  estimated  by  determining  its 
specific  gravity.  This  he  does  by  blowing  a  drop  of  blood  into  mixtures 
of  glycerin  and  water  of  known  specific  gravities  from  1040-1076  cor- 
responding to  the  normal  specific  gravity  of  the  blood  and  noticing 
whether  it  sank,  rose  or  remained  for  a  time  suspended.  A  small  urin- 
ometer  suffices  to  determine  the  specific  gravities  of  the  glycerin  and 
water  mixture. 

The  state  of  the  circulation  is  gauged  by  the  sphygmomanometer. 

If  the  pressure  is  70  mm.  or  over,  saline  may  be  absorbed  from  the 


648  TREATMENT  OF  ACUTE  INFECTIOUS  DISEASES 

bowel  and  unless  indications  are  urgent  treatment  may  be  begun  in 
this  manner. 

He  uses  a  solution  of  sodium  chloride  gr.  90  to  one  pint  (6  Gm.  to 
500  c.c.)  at  blood  heat  1/2  to  1  pint  (250-500  c.c.)  introduced  very 
slowly  two  hours  or  by  the  Murphy  drip  method. 

This  is  kept  up  until  the  kidneys  act  freely. 

If,  however,  the  blood  pressure  is  below  70  mm.  Hg.,  or  the  patient 
has  severe  cramps,  is  restless  or  cyanotic  a  saline  should  be  given 
intravenously  as  the  subcutaneous  method  is  often  ineffectual  due  to 
failure  of  absorption.  Owing  to  the  collapse  of  the  vein  it  is  usually 
necessary  to  cut  down  upon  the  vein  to  insert  the  needle. 

The  efficacy  of  this  method  Rogers  attributes  largely  to  the  con- 
centration of  the  solution.  The  formula  he  advises  is  as  follows: 

Sodium  Chloride 120  grains.  (8  Gm.) 

Calcium  Chloride 4  grains.  (0.250  Gm.) 

Potassium  Chloride 6  grains.  (0 . 370  Gm.) 

To  each  pint  of  water  (500  c.c.). 

This  is  injected  at  body  temperature. 

Three  to  four  pints  are  usually  injected,  aiming  to  bring  the  blood 
pressure  up  to  110  mm.  Hg.  The  injection  is  carried  on  at  the  rate  of 
about  1  pint  in  five  minutes. 

A  salvarsan  apparatus  with  a  large  container  may  be  used  for  this 
purpose.  (See  Pneumonia,  Chap.  IX.) 

Indications  for  interruptions  of  the  injection  or  lessening  the  rate 
of  inflow  are  headache,  dyspnoea  or  sense  of  oppression  in  chest. 

Rogers'  second  point  of  attack  is  on  the  toxins  of  this  disease  before 
absorption. 

For  this  purpose  he  advocates  highly  the  use  of  calcium  or  potas- 
sium permanganate,  preferably  calcium  as  an  oxidizing  agent. 

He  gives  it  in  the  drinking  water,  4  or  more  grains  to  the  pint  (0.25 
Gm.  to  100  c.c.)  (much  more  than  4  is  not  readily  swallowed)  in 
such  quantities  as  the  patient  can  be  made  to  drink,  or  in  gr.  ii  (0.125 
Gm.)  pills  coated  with  salol  (phenyl  salicylate)  or  keratin  every  quarter 
hour  for  four  doses,  then  every  half  hour  until  gr.  xx  are  taken,  in  four 
hours,  then  omit  four  hours  (or  take  gr.  v  (0.30  Gm.)  bismuth  salicylate 
every  hour  for  these  four  hours),  then  one  pill  every  half  hour  for  four 
hours,  then  stop  four  hours  and  so  on  over  again  until  stools  change 
color  and  become  less  (usually  in  twenty-four  hours). 

At  the  beginning  of  the  second  day  16  grains  more  are  administered. 

Lately  Rogers  has  been  using  atropine  sulphate  gr.  1/100  (0.006  Gm.) 
morning  and  night  with  satisfactory  results. 

Sellards  uses  0.5  per  cent,  saline  solution  and  0.5  per  cent,  sodium 


ASIATIC  CHOLERA  649 

bicarbonate  solution,  injecting  in  the  adult  as  much  as  two  litres  of  saline 
at  an  interval  of  15-20  minutes.  The  improvement  is  often  very  great, 
but  purging  continues  and  collapse  is  almost  certain  to  return.  He  re- 
peats the  infusion  at  6  to  8  hour  intervals.  He  notes  that  patients  who 
recover  begin  to  show  inprovement  on  the  second  day. 

Sellards  did  not  find  that  the  hypertonic  solution  used  by  Rogers  and 
others  afforded  the  results  that  theory  seemed  to  promise. 

Other  substances,  such  as  colloidal  solutions,  added  to  the  saline 
failed  to  convince  Sellards  of  an  additional  value. 

Vomiting.  As  lesser  measures  one  may  try  cracked  ice  or  a  mustard 
paste  to  the  epigastrium  or  subcarbonate  of  bismuth  in  gr.  xv  (1  Gm.) 
doses  or  if  the  vomiting  is  very  severe  lavage  may  be  tried.  In  the 
early  stages  a  hypodermic  of  morphine  sulphate  gr.  1/4  (0.015  Gm.)- 
is  warrantable  and  perhaps  more  likely  to  be  efficacious  than  any 
other  measure,  but  during  the  stage  of  collapse  Rogers  maintains  its  use 
constitutes  a  real  danger. 

During  collapse  warmth  to  the  surface  of  the  body  is  indicated  by 
the  applications  of  hot  blankets  and  hot-water  bottles.  Hot  drinks 
are  also  given,  friction  to  the  skin  and  extremities  and  stimulants  ad- 
ministered (see  below).  Heat,  however,  should  not  be  applied  during 
intravenous  injection  as  the  febrile  reaction  accompanying  it  may  pass 
over  into  hyperpyrexia. 

Stage  of  Reaction.  With  a  cessation  of  vomiting,  a  diminution 
in  the  stools,  improvement  in  their  consistency  and  color  (bile  re- 
tained), a  slowing  of  the  pulse,  and  wanning  of  the  body  surface,  the 
stage  of  reaction  sets  in  and  brings  hope  with  it  and  yet  this  period  is 
fraught  with  no  inconsiderable  dangers  that  has  warned  the  physician 
to  abate  no  jot  or  tittle  in  his  vigilance. 

The  possibilities  for  disaster  in  this  stage  rest  in  hyperpyrexia,  sup- 
pression of  urine  and  ursemia. 

Hyperpyrexia.  Large  bodies  of  statistics  attribute  10  per  cent,  of 
deaths  to  hyperpyrexia.  Rogers  believes  it  due  not  so  much  to  pyrexia 
as  the  rapid  absorption  of  toxins  from  the  gut  as  the  circulation  picks  up 
under  the  febrile  reaction. 

He  believes  his  permanganate  treatment  has  lessened  the  mortality 
from  this  cause.  He  also  warns  against  the  use  of  heat  applied  to  surface 
of  the  body  during  saline  infusion. 

Anuria  is  to  be  met  by  the  supply  of  fluid  to  the  tissues  by  fre- 
quent administrations  by  mouth  and  rectum  and  if  specific  gravity 
of  blood  is  not  too  low  (Rogers)  by  vein  as  saline  solutions. 

Sellards  recommends  intravenous  injections  of  2  per  cent,  sodium 
bicarbonate  in  place  of  normal  or  hypertonic  saline  as  being  more  effica- 


650  TREATMENT  OF  ACUTE  INFECTIOUS  DISEASES 

cious  in  this  Condition,  while  be  believes  it  is -equally  potent  in  relieving 
collapse. 

The  kidneys  may  be  cupped,  cardiac  stimulants  such  as-strophan- 
thin  gr.  1/120-gr.  1/60  (0.0005-0.001  Gm.)  or  rapid  vaso-motor  stimu- 
lants such  as  adrenalin  m.  x-xv  (0.60-1  c.c.)  into  muscle  or  m.  ii-v 
(0.125-0.30  c.c.)  into  vein  to  be  used. 

Uremia  is  particularly  likely  to  occur  even  in  the  milder  cases, 
in  the  state  of  reaction,  and  Sellards'  studies  show  it  is  connected  inti- 
mately with  an  acidosis.  Because  of  this  tendency  toward  acidosis 
Sellards  early  in  the  stage  of  reaction  increases  the  strength  of  the  solu- 
tion used  in  collapse  to  1.5  per  cent,  of  sodium  bicarbonate  and  omits  the 
sodium  chloride. 

•    If  the  urine  does  not  become  alkaline  to  litmus  or  but  little  urine  is 
passed  he  increases  the  strength  to  2  per  cent,  sodium  bicarbonate. 

Proper  precaution  in  the  sterilization  of  the  sodium  bicarbonate  solu- 
tion must  be  taken  to  prevent  its  conversion  into  sodium  carbonate. 
This  may  be  done  by  passing  carbon  dioxide  gas  through  the  sterilized 
solution  until  the  carbonate  is  reconverted  into  the  bicarbonate.  The  gas 
is  passed  through  sterile  tubes  and  filtered  through  sterile  cotton  before 
it  enters  the  solution. 

Even  60  to  90  grams  of  sodium  bicarbonate  was  given  intravenously 
within  24  to  48  hours  with  most  satisfactory  results. 

The  method  of  intravenous  infusion  is  described  in  detail  under  the 
administration  of  serum  in  pneumonia,  Chap.  IX.  The  rate  is  much 
more  rapid  than  in  serum  injection.  Two  litres  may  be  given  within 
15  to  30  minutes.  The  intervals  are  6  to  8  hours  or  on  the  reappearance 
of  collapse.  Bicarbonate  is  discontinued  when  the  urine  becomes  al- 
kaline. 

Specific  Treatment.  Serum  has  been  used  but  unfortunately  as 
yet  with  little  result.  Prophylactic  inoculations  of  the  cholera  vibrio 
by  Haffkine  have  been  adopted.  Such  treatment  after  evidences  of 
infection  occur  is  of  no  value  and  there  are  theoretical  reasons  for  the 
belief  that  it  is  then  distinctly  harmful. 

Stimulants.  A  sufficiency  of  water  in  the  circulation  is  the  best 
stimulant  and  that  the  intravenous  injection  seeks  to  assure.  However, 
if  this  fails,  we  must  use  whatever  other  means  we  have  at  hand  that 
gives  us  any  promise  of  assistance  and  look  for  such  among  the  drugs. 

Probably  no  drug  is  comparable  to  digitalis  for  sustained  effect  upon 
the  circulation  and  should  be  administered  in  doses  of  m.  xx  (1.30  c.c.) 
of  the  tincture  every  six  hours.  It  requires  some  thirty-six  hours  or 
more,  however,  for  it  to  exert  its  effect  and  it  seems  to  me  that  for  more 
immediate  effect  strophanthin  in  doses  of  mg.  1/2-1  (gr.  1/120-1/60)  in- 


ASIATIC  CHOLERA  651 

travenously  would  be  indicated  here  as  in  other  acute  infections  accom- 
panied by  circulatory  failure. 

For  vaso-motor  stimulants  one  may  have  recourse  to  camphor  gr. 
v  (0.30  Gm.)  in  oil  or  caffeine  sodio-salicylate  or  caffeine  sodio-benzoate 
gr.  v  (0.30  Gm.)  in  watery  solution  every  four  hours  or  alternate  at  two- 
hour  intervals  or  strychnine  sulphate  gr.  1/40  (0.0015  Gm.)  every  three 
to  four  hours. 

All  should  be  given  deep  into  a  muscle  or  if  collapse  is  severe  into  a 
vein. 

Sellards  would  allow  coffee  in  small  amounts  as  being  both  agreeable 
and  possibly  beneficial  to  both  heart  and  kidneys. 

Prophylaxis.     Wherry  has  divided  this  subject  into 

(1)  Communal  and  (2)  Individual  Prophylaxis. 

Communal  Prophylaxis.  This  means  proper  quarantine,  sani- 
tary supervision  and  control  of  water  and  food  supply,  bacterial  ex- 
amination of  the  excreta  of  all  suspects,  which  includes  all  persons 
coming  from  foci  of  infection,  many  of  whom  may  be  true  carriers, 
themselves  free  from  any  symptoms  of  the  disease. 

Isolation  of  Suspects.  This  should  entail  a  detention  of  at  least 
five  days. 

Individual  Prophylaxis.  This  entails  the  realization  that  the  in- 
fection enters  by  the  mouth;  that  it  comes  by  way  of  drinking  water; 
hence,  all  water  should  be  boiled ;  that  it  comes  by  way  of  food ;  hence, 
only  recently  cooked  foods,  carefully  protected  from  flies,  and  no  raw 
foods  should  be  eaten;  that  it  comes  from  fingers  or  utensils  soiled  by 
excreta;  hence,  careful  sterilization  of  utensils,  protection  of  hands  by 
gloves,  when  in  contact  with  patients,  and  by  cleansing  in  sterile  water 
and  antiseptic  solutions ;  that  it  comes  from  flies  or  other  insects  bearing 
excreta  on  their  legs  to  food  and  drink;  hence,  screening  of  patient  and  of 
food ;  that  anything  which  reduces  the  resistance  of  the  epithelial  lining  of 
the  intestine  enhances  the  likelihood  of  an  attack;  hence,  especial  atten- 
tion should  be  given  to  diet  during  a  cholera  epidemic.  This  means  eat- 
ing in  moderation,  avoidances  of  all  questionable  messes  and  highly  sea- 
soned and  garnished  dishes;  raw  fruits  and  vegetables,  large  quantities 
of  very  cold  water  and  alcoholic  excesses. 

Vaccines  have  been  used  as  a  prophylactic  measure  with  some  degree 
of  success. 

These  vaccines  have  been  variously  prepared  and  administered  and 
it  seems  probable  that  their  use  will  become  more  extensive. 

Complications.  These  are  numerous  but  pneumonia,  prolonged 
dysentery,  profound  weakness  determining  a  long  convalescence  are 
the  most  common. 


652  TREATMENT  OF  ACUTE  INFECTIOUS  DISEASES 

Convalescence  is  to  be  met  by  a  careful  -return  to  a  sufficient  diet, 
good  air  and  rest. 

I  cannot  do  better  than  quote  bodily  the  summary  of  treatment 
from  Rogers  to  whose  excellent  article  I  owe  so  much. 

Summary  of  Rogers'  Treatment.  "In  the  first  place,  the  blood- 
pressure  and  specific  gravity  of  the  blood  should  be  estimated  and  the 
axillary  and  rectal  temperature  taken.  If  the  blood-pressure  is  70 
millimeters  of  Hg.  or  over,  the  patient  quiet,  and  the  general  condition 
good,  rectal  saline  injections  may  be  tried,  a  careful  watch  being  kept  on 
the  pulse,  so  that  any  further  fall  may  at  once  be  detected  and  more 
active  measures  adopted.  If  the  specific  gravity  is  very  high,  such  as 
1070,  transfusion  should  not  be  delayed.  If  the  blood-pressure  on 
admission  or  later  falls  below  70,  and  especially  if  the  patient  is  restless, 
cyanosed,  and  suffering  from  severe  cramps,  no  time  should  be  lost  in 
giving  an  intravenous  injection,  the  hypertonic  Ringer  solution  being 
used.  Sufficient  should  be  injected  to  obtain  not  only  a  fair,  but  a  strong, 
full  pressure-pulse,  so  as  to  at  once  restore  the  urinary  secretion.  Four 
pints  are  commonly  necessary  in  a  severe  case  in  an  adult  male,  and  pro- 
portionately less  in  women  and  children.  It  should  be  given  at  body  heat 
unless  the  rectal  temperature  is  below  90°  F.,  when  the  temperature  of 
the  solution  should  be  a  few  degrees  higher  until  the  surface  temperature 
is  restored.  A  careful  watch  should  be  kept  on  the  temperature  reaction 
which  always  follows  intravenous  salines,  and  the  necessary  measures 
taken  to  prevent  an  excessive  rise  occurring. 

"In  the  acute  stage  nothing  should  be  given  by  the  mouth  except 
the  permanganate,  drinks  and  pills,  and  some  antiseptic,  such  as  bismuth 
salicylate.  If  the  acute  stage  is  prolonged,  barley-water  may  also  be 
necessary.  If  the  collapse  recurs,  the  hypertonic  injection  must  be 
repeated,  being  given  at  a  slower  rate  if  the  specific  gravity  of  the  blood 
is  not  much  raised,  and  at  a  subnormal  temperature  if  there  is  fever 
present. 

"If  a  second  hypertonic  injection  is  required,  the  prognosis  be- 
comes much  graver,  although  a  majority  of  even  such  cases  may  be 
saved. 

"Once  the  stage  of  copious  evacuations  and  collapse  is  past,  the  all- 
important  indication  is  to  dilute  the  blood  to  at  least  the  normal  point, 
and  to  raise  the  blood-pressure  high  enough  to  restore  the  secretory 
activity  of  the  kidneys,  and  so  insure  the  excretion  of  the  toxins  and  the 
prevention  of  the  uraemic  complications.  If  the  specific  gravity  of  the 
blood  remains  above  normal,  and  is  not  rapidly  reduced  by  continuing 
the  salines  by  the  bowel  and  the  water  by  the  mouth,  a  further  smaller 
subcutaneous  or  slow  intravenous  injection  of  normal  saline  solution  is 


ASIATIC  CHOLERA  653 

indicated.  In  addition,  cardiac  tonics  and  vaso-constricting  drugs  are 
of  great  service. 

"Great  caution  is  necessary  in  adding  to  the  diet  during  early  con- 
valescence, animal  albumins  being  especially  liable  to  induce  a  relapse, 
while  starvation  for  two  or  three  days  is  less  injurious  in  otherwise 
healthy  subjects  whose  age  is  not  at  either  extreme  of  the  scale."  (Hare's 
Modern  Treatment.) 

For  Sellards'  treatment,  see  text. 

SUMMARY 

Isolation. 

Of  all  real  cases  and  all  suspects  (those  who  during  an  epidemic 
have  diarrhea). 

Destruction  of  all  dejecta  and  sterilization  of  objects  coming  in  con- 
tact with  the  patient  or  his  excretions. 

(For  details,  see  Typhoid  Fever,  Chap.  XIV.) 

Doctor  and  nurse. 

Should  use  gowns  and  gloves  in  performance  of  duties  about  patient. 
Cleanse  hands  with  soap  and  water,  and  follow  with  alcohol  or  1  to 
1,000  bichloride,  even  if  gloves  were  worn. 

Room. 

Chosen  with  reference  to  ventilation. 
Stripped  of  all  hangings  and  ornaments. 
Take  especial  care  to  keep  flies  from  the  room  and  dejecta. 
(For  details  of  care  of  room,  care  of  the  bed,  and  sterilization  of  ob- 
jects, see  Typhoid  Fever,  Chap.  XIV.) 

Diet. 

At  first  only  barley-water,  best  given  hot. 

Little  later  other  farinaceous  gruels. 

Arrowroot  water. 

Rice  water. 

Animal  broths  thickened  with  farinaceous  foods  (cautiously). 

Whey,  then 

Milk. 

Water  freely  in  small  quantities  frequently,  not  too  cold. 

Rest. 

Put  to  bed  at  earliest  sign  of  diarrhea. 
Give  hot  drinks,  weak  tea  or  lemonade. 
Cover  warmly. 

Hot  stupes  or  poultices  to  abdomen. 
(For  technique  of  stupes,  see  Chap.  XIV.) 
(For  technique  of  poultices,  see  Chap.  IX.) 


654  TREATMENT  OF  ACUTE  INFECTIOUS  DISEASES 

Opium.  M 

May  be  given  early,  not  late. 
Tr.  opii  m.  xx  (1.30  c.c.). 
Paregoric  gss.  to  i  (15-30  c.c.). 
May  divide  above  doses  and  give  at  short  intervals 
Dover's  powder  gr.  1/5  (0.010  Gm.)  every  hour. 

Cathartics. 

Should  not  be  used  at  all. 

Rogers'  treatment  of  hypertonic  salt  solutions  and  potassium  per- 
manganate.   (See  text.) 

Vomiting. 

Cracked  ice  to  suck. 

Mustard  paste  to  epigastrium.    (For  technique,  see  index.) 

Bismuth  subnitrate  in  doses  of  gr.  xv  (1  Gm.). 

If  severe,  lavage. 

Morphine,  gr.  1/4  (0.015  Gm.). 

Collapse. 

Warmth  to  body. 
Blankets. 
Hot-water  bottles. 
Friction  to  the  extremities. 
Stimulants,  see  below. 
Conditions  arising  during  the 

Stage  of  reaction. 

Hyperpyrexia. 
Cold  sponges. 

Anuria. 

Fluid  to  tissues.    (See  Rogers'  treatment,  text.) 
Cup  kidneys.    (For  technique  of  cupping  see  index.) 
Cardiac  and  vaso-motor  stimulants,  see  below. 
Specific  treatment. 

(See  text.) 
Stimulants. 

Sufficiency  of  fluids  to  the  tissues. 

Digitalis,  m.  xx  (1.30  Gm.)  every  six  hours. 

Strophanthin  in  urgent  cases  gr.  1/120  to  gr.  1/60  (0.0005-0.001 

Gm.)  to  initiate  the  digitalis. 
Camphor  gr.  v  (0.30  Gm.)  in  oil  5  per  cent,  or 
Caffeine  sodium  benzoate,  gr.  v  (0.30  Gm.)  either  every  four  hours 

or  alternate  one  with  the  other  every  two  hours,  or 
Strychnine  sulphate,  gr.  1/40  (0.0015  Gm.) ;  all  given  into  muscle 

or  vein. 
For  immediate  effect 

Adrenalin  m.  xv  (1  c.c.)  into  muscle  or  m.  iii  (0.20  c.c.)  into 
vein. 


ASIATIC  CHOLERA  655 

Prophylaxis. 

1.  Communal. 

Quarantine. 

Supervision  and  control  of  water  and  food  supply. 
Bacterial  examination  of  excreta  of  all  suspects. 
Isolation  of  suspects  for  five  days. 

2.  Individual. 

Boil  water. 

Don't  drink  large  amounts  of  cold  water.    Avoid  alcohol. 

Eat  no  raw  foods. 

Eat  only  recently  cooked  foods. 

Protect  food  from  flies. 

Eat  in  moderation. 

Sterilization  of  utensils. 

Protection  of  hands  with  gloves  when  in  contact  with  patients. 

Convalescence. 

Careful  return  to  sufficient  diet. 
Fresh  air. 


CHAPTER  XXXII 

MALTA  FEVER 

MALTA  FEVER  in  the  great  ocean  of  diseases,  has  like  its  habitat 
Malta  seemed  until  recently,  an  island  and  a  small  island  at  that,  of 
interest  only  to  the  physician  practicing  there  or  treating  the  Eng- 
lish soldier  invalided  home,  but  an  article  by  Ferenbaugh  in  August, 
1911,  suddenly  made  us  aware  that  we  harbored  the  disease  in  this 
country  in  the  great  State  of  Texas. 

This  disease,  which  affected  so  widely  the  British  troops  stationed 
in  Malta,  Gibraltar  and  a  few  other  Mediterranean  localities  was  found 
by  Bruce  in  1887  to  be  due  to  a  definite  organism,  the  bacterium  meli- 
tensis.  The  mode  of  its  distribution  was  elucidated  by  the  Mediterra- 
nean Fever  Commission  in  their  work  of  1905-7.  They  showed  that  it 
came  largely  through  the  use  of  the  milk  of  goats  so  plentiful  in  the  is- 
land; that  50  per  cent,  of  the  goats  were  infected,  acting  as  carriers,  and 
that  10  per  cent,  of  them  secreted  the  bacteria  in  their  milk. 

In  Edwards  County,  Texas,  and  in  adjacent  territory  an  unclassified 
slow  fever  had  been  recognized  under  various  local  designations  and  had 
even  been  associated  with  the  goat  and  by  some  called  "goat  fever." 
The  investigators  mentioned  found  all  their  cases  to  be  in  the  goat  raising 
country,  among  those  drinking  uncooked  goats'  milk  or  handling  goats 
(for  the  Mediterranean  Fever  Commission  found  these  animals  excreted 
the  bacteria  in  their  urine  and  feces  as  well  as  in  their  milk),  and  though 
the  organisms  were  not  found  in  the  milk  of  the  Texas  goat,  34  per  cent, 
gave  a  positive  reaction  to  the  agglutination  test. 

The  complement  fixation  test  has  since  been  used  in  the  investigation 
with  positive  results. 

Gentry  and  Ferenbaugh  give  the  warning  that  some  of  the  so-called 
typhoid  fever  cases  in  these  sections  might  prove  to  be  Malta  Fever. 

The  incubation  period  seems  to  be  about  two  weeks. 

The  disease  is  characterized  by  the  peculiar  course  of  the  fever,  the 
curve  of  which,  rising  and  falling  like  the  waves  of  the  sea,  have  given 
it  the  name  of  undulating  fever. 

It  is  very  drawn  out,  often  lasting  months  (averages  give  90-120 
days — some  last  a  year  or  more)  and  is  rife  with  discomforts,  such  as 
headache,  backache,  neuralgic  pains,  swollen  painful  joints,  perspiration, 
gastric  disturbance,  and  not  uncommonly  an  orchitis. 


MALTA  FEVER  657 

Relapses  are  the  rule  and  are  repeated. 

Treatment.  Here,  as  in  most  diseases,  our  best  treatment  lies  in 
husbanding  the  patient's  strength  for  his  own  battle  with  the  infection. 

This  is  achieved  by  rest,  consideration  of  the  diet  and  good  nursing. 

Bed.  Certainly  during  the  febrile  exacerbations  and  during  the 
period  of  pain  the  patient  should  be  kept  in  bed  and  will  undoubtedly 
be  willing,  but  during  the  remissions  an  insistency  on  the  bed  may  not  be 
feasible,  but  a  maximum  amount  of  quiet  should  be  enjoined. 

Each  febrile  period  is  considerably  prolonged  and  the  bed  should 
be  chosen  with  a  view  to  comfort  and  convenience  as  in  Typhoid  Fever. 
(See  Chap.  XIV.) 

In  a  state  of  so  great  discomfort  good  nursing  counts  for  much;  quiet 
should  be  secured,  every  annoyance  avoided  and  the  bed-pan  be  in- 
sisted upon. 

The  room  should  be  cool  and  shady  and  screened  against  insects. 

The  urine  and  feces  which  contain  the  organisms  should  be  destroyed, 
and  clothes,  bedclothes  and  utensils  sterilized  as  in  Typhoid  Fever  cases. 

Nurses  and  physicians  appreciating  the  mode  of  infection  should 
guard  against  it  by  wearing  gloves  when  handling  contaminated  ob- 
jects and  carefully  clean  their  hands.  The  rules  given  under  Typhoid 
Fever  serve  here.  (See  Chap.  XIV.) 

Care  of  the  Body.  Sponge  baths  with  soap  and  water,  talcum 
powders,  alcohol  rubs,  frequent  changing  of  position  keep  the  skin 
in  condition  and  avoid  bed-sores.  The  mouth  and  nose  should  be  kept 
free  from  secretions,  the  tongue  and  teeth  especially  looked  after. 

It  has  been  advised,  on  account  of  the  neuralgias  and  joint  pains, 
that  just  as  in  rheumatism  the  clothes  next  the  skin  should  be  of  flannel 
or  contain  wool,  and  this  the  more  especially  because  the  perspiration 
is  profuse  and,  when  cotton  garments  become  wet  through,  chilling  of 
the  skin  may  ensue.  Of  course  frequent  change  of  clothes  for  the  same 
reason  is  demanded.  For  details  (see  Typhoid  Fever,  Chap.  XIV.) 

Diet.  The  general  rule  for  feeding  in  fever  should  be  followed 
(Diet  in  Acute  Infectious  Diseases,  Chap.  II)  with  a  view  to  caloric 
needs  and  that,  especially,  because  the  fever  is  long  drawn  out.  As, 
however,  the  gastro-intestinal  canal  is  in  an  irritable  condition  in  the 
early  days,  food  should  not  be  forced  and  should  at  first  consist  of  diluted 
milk,  with  soups,  cereal  waters  and  jellies,  and  meat  broths  (if  desired) 
which  may.be  thickened  with  cereals  or  farinaceous  meals  to  enhance 
their  food  values. 

Goat's  milk  should  not  be  used,  but  if  deemed  imperative  it  should 
be  boiled  or  at  the  least  be  pasteurized  to  kill  any  bacteria  melitenses 
that  may  be  present. 


658  TREATMENT  OF  ACUTE  INFECTIOUS  DISEASES 

Drinks.  Water,  saline  waters  or  drinks,  containing  fruit  juices 
should  be  given  freely. 

Bowels.  The  bowels  should  be  freely  opened  at  the  .beginning 
with  calomel  and  salts  or  salines  alone,  Calomel  gr.  iii  to  v  (0.2-0.35 
Gm.)  followed  by  Epsom  or  Rochelle  salt  5ss.  to  i  (15-30  Gm.).  The 
calomel  may  be  given  in  divided  doses  of  gr.  1/4  (0.015  Gm.)  every  ten  to 
fifteen  minutes  for  eight  or  ten  doses. 

Constipation  is  the  rule  throughout  the  disease  and  the  use  of  enemata 
or  drugs  cannot  be  dispensed  with.  Calomel  has  been  much  used  be- 
cause in  addition  to  its  cathartic  action  it  has  been  assumed  to  exert  a 
good  effect  upon  the  disease  itself  and  jalap  for  the  same  reason. 

Of  course  this  usage  rests  on  individual  opinion  and  not  on  a  rational 
basis. 

Better  for  this  purpose  it  seems  to  me  are  the  milder  salines,  citrate  of 
magnesia,  Hunyadi  water  and  the  like,  cascara,  compound  licorice 
powder,  aloin  and  occasionally  more  drastic  salines  like  Epsom,  Rochelle 
or  Glauber's  salt  or  castor  oil. 

Retention  of  urine  sometimes  occurs  and  should  be  looked  for. 
Hot  fomentations  to  the  hypogastrium  or  the  sound  of  running  water 
may  relieve  this;  if  not  the  catheter  must  be  used  with  all  due  caution 
to  prevent  infection. 

Specific  treatment  has  as  yet  been  illy  developed;  vaccines  have 
been  used  in  the  more  chronic  forms  of  the  disease  and  good  results  have 
been  reported.  It  would  seem  a  legitimate  field  of  endeavor,  but  their 
use  should  not  be  undertaken  in  the  acute  manifestations  of  the  disorder 
except  by  men  well  versed  in  the  theory  and  application  of  vaccine 
therapy,  as  real  harm  may  be  done. 

In  the  suitable  cases  the  dosage  has  been  5,000,000  bacteria  and 
the  number  of  doses  one  to  ten  (Basset-Smith).  Some  use  as  high  as 
50,000,000. 

Symptomatic  Treatment.  The  discomforts  of  the  disease  are  so 
great  that  a  considerable  demand  is  made  on  medical  procedure. 

Pain.  Neuralgic  pains,  joint  pains,  backache  and  headache  are  con- 
stant and  characteristic  phenomena. 

When  it  is  possible  the  measures  of  physical  therapy  should  be  given 
preference,  such  as  the  ice-bag  to  the  head,  hot  cloths  to  the  back  and 
joints  or  mustard  plasters  or  poultices  or  massage  or  light  rubbing  with 
or  without  liniments  and  counter-irritants  such  as  chloroform  liniment 
or  a  10-15  per  cent,  methyl-salicylate  or  menthol  or  the  two  combined. 

The  joints  should  be  treated  as  in  rheumatism,  swathed  in  cotton 
batten  or  flannel  and  if  it  affords  more  comfort,  mobilized.  (See  Rheu- 
matic Fever,  Chap.  III.) 


MALTA  FEVER  659 

If  drugs  are  used,  one  may  try  acetyl  salicylic  acid  (aspirin)  or  other 
form  of  salicylate  in  doses  of  gr.  x-gr.  xv  (0.65-1  Gm.)  every  two  hours  or 
coal  tars,  acetphenetidin  (phenacetin)  gr.  iv  to  gr.  viii  (0.25-0.5  Gm.)  at 
the  same  intervals  or  acetanilid  gr.  ii  to  gr.  iv  (0.15-0.25  Gm.) 

These  drugs,  however,  have  been  very  disappointing  and  in  the 
severest  cases  morphine  has  to  be  used. 

Fever.  When  within  proper  limits,  104°  F.  or  less,  this  requires  no 
other  treatment  than  that  directed  at  comfort  such  as  follows  a  cool 
sponge  bath;  but  in  hyperpyrexia  105°  F.  or  above  or  even  104°  F.  or 
less,  when  very  sustained,  measures  aimed  at  it  should  be  pursued  and 
none  are  comparable  to  cold  water. 

The  procedures  and  their  details  when  there  is  sustained  fever  will  be 
found  under  Typhoid  Fever  (see  Chap.  XIV  and  may  be  adapted  in 
regard  to  temperature,  length  and  frequency  of  bath  and,  indeed,  in  all 
particulars.  In  cases  of  sudden  high  temperature  the  rules  given  under 
"Rheumatic  Fever"  (Chap.  Ill)  should  be  followed.  Hyperpyrexia  is 
one  of  the  real  dangers  of  the  disease  and  should  be  watched  for  and 
provision  made  for  prompt  treatment.  When  cold  water  cannot  be 
obtained,  antipyretics  may  be  used  but  they  are  illy  efficient  and  danger- 
ously depressant.  In  the  lower  temperatures  they  should  not  be  used. 

Vomiting.  During  vomiting  food  should  be  stopped  or  if  the  vomit- 
ing is  persistent  give  small  quantities  of  egg  albumin,  beef -juice,  or 
milk  peptonized  or  diluted  in  water  or  cereal  water.  Champagne  is 
sometimes  well  borne,  lessens  vomiting  and  furnishes  a  little  fuel  in  its 
alcohol  content. 

Cracked  ice  may  be  used,  mustard  paste  1  part  of  mustard  to  3  or  4  of 
flour,  or  mustard  leaf  may  be  applied  to  the  pit  of  the  stomach,  bismuth 
subnitrate  gr.  xv  to  gr.  xxx  (1-2  Gm.),  bicarbonate  of  soda  gr.  x  to  gr.  xv 
(0.65-1  Gm.),  cerium  oxalate  gr.  v  to  gr.  x  (0.35-0.65  Gm.)  may  be  given 
singly  or  in  combination. 

In  very  severe  cases  cocaine  hydrochloride  gr.  1/5  (0.012  Gm.)  may  be 
of  value,  or  calomel  in  gr.  1/10  (0.006  Gm.)  doses,  or  if  exhaustion 
threatens  morphine  sulphate  gr.  1/8  to  gr.  1/4  (0.008-0.015  Gm.)  hy- 
podermically. 

Sleeplessness  may  require  bromides  in  early  evening  in  gr.  xxx  (2 
Gm.)  doses  or  trional  gr.  x  to  gr.  xx  (0.65-1.35  Gm.)  or  chloralamid 
gr.  xv  to  gr.  xxx  (1-2  Gm.)  or  in  prolonged  or  persistent  sacrifice  of 
sleep  chloral  gr.  x  to  gr.  xv  (0.65-1  Gm.)  or  even  morphine  gr.  1/8  (0.008 
Gm.)  hypodermically. 

Toxemia.  If  this  is  marked  the  hydrotherapeutic  measures  men- 
tioned under  hyperpyrexia  will  be  found  most  efficient. 

If  the  circulation  is  threatened  digitalis  should  be  given  in  doses 


660  TREATMENT  OF  ACUTE  INFECTIOUS  DISEASES 

of  the  tincture  m.  xxx  (2  c.c.)  three  or  four  times  a  day  for  three  or  four 
days  or  the  equivalent  dose  of  the  infusion  5  ss.  (15  c.c.)  or  powdered 
leaf  gr.  iii  (0.2  Gm.). 

For  more  immediate  effect  the  vaso-motor  stimulants  caffeine  in 
soluble  form,  double  salt  of  sodium  salicylate  or  benzoate  gr.  v  (0.35 
Gm.)  every  four  or  every  two  hours  intramuscularly  or  camphor  gr. 
v  (0.35  Gm.)  in  oil,  10  per  cent,  by  the  same  method  at  the  same  intervals. 

Orchitis.  Is  not  an  uncommon  complication.  It  is  to  be  treated 
like  orchitis  from  other  causes.  The  testicle  is  supported,  hot  fomen- 
tations applied  or  "dry  poultices,"  i.  e.,  a  heavy  non-absorbent  cotton 
dressing  and  counter-irritants  used,  of  which  light  application  of  the 
actual  cautery  is  the  best.  (See  Parotitis,  Chap.  XXIII.) 

Convalescence.  Fresh  air  and  plenty  of  good  food  are  the  best 
tonics  during  convalescence,  though  iron  as  carbonate  gr.  ii  to  gr.  v 
(0.15-0.35  Gm.)  arsenic  gr.  1/40  to  gr.  1/30  (0.0015-0.002  Gm.)  and 
strychnine  gr.  1/40  to  gr.  1/30  (0.0015-0.002  Gm.)  may  be  used  singly 
or  in  combination. 

Prognosis  is  good,  the  mortality  is  only  about  2  per  cent,  to  3  per 
cent,  and  immunity  against  a  second  attack  is  probably  conferred. 

Prophylaxis.     The  etiology  makes  the  problem  clear. 

The  infected  goat  should  be  eliminated  from  the  herd,  and  tests 
made  of  herds  in  infected  districts  from  time  to  time.  When  this  is 
not  possible  the  goat's  milk  in  infected  districts  should  not  be  drunk  or  at 
least  should  be  boiled  or  pasteurized  before  using. 

Knowledge  should  be  disseminated  in  infected  districts  of  the  possi- 
bility of  infection  from  handling  the  goat,  whose  urine,  feces  and  milk 
excrete  the  organism. 

Care  should  be  taken  lest  the  water  supply  or  food  be  contaminated 
by  the  excreta. 

Filth  harbors  the  infection  while  sunlight  readily  kills  the  bacterium; 
hence,  the  importance  of  cleanliness  and  light. 

The  patient's  excreta,  too,  containing  the  bacteria  are  sources  of 
infection  and  should  be  properly  disposed  of  as  mentioned  above. 

It  is  well  to  screen  the  windows  and  doors  against  insects  that  may 
bear  infected  excreta  on  their  bodies  to  food;  for  by  food  the  disease  is 
nearly  always  conveyed. 

As  in  typhoid  fever  some  of  the  patients  become  carriers  after  con- 
valescence and  have  been  shown  to  excrete  the  bacteria  for  two  years. 


MALTA  FEVER  661 

SUMMARY 

Rest. 

In  bed;  certainly,  during  exacerbations. 

Bed. 

(For  technique  of  bed-making,  see  Typhoid  Fever,  Chap.  XIV,  or 
Dysentery,  Chap.  XVI.) 

Room. 

Cool  and  shady.    Screen  against  flies. 

Urine,  stools,  bedclothes,  utensils,  etc.    (See  Typhoid  Fever,  Chap. 
XIV.) 

Physicians  and  Nurses. 
Should  wear  gloves  in  handling  secretions. 
(See  Typhoid  Fever,  Chap.  XIV.) 

Care  of  the  body. 

Sponge  baths,  daily,  with  soap  and  water. 
Talcum  powder. 
Alcohol  rubs. 

Frequent  change  of  position. 
Mouth,  teeth,  etc. 

(See  Pneumonia,  Chap.  IX.) 
Woolen  next  to  the  skin  on  account  of  neuralgias,  joint  pains  and 

abundant  perspiration. 

Diet. 

Early  days. 
Diluted  cow's  milk   (not  goat's),  soups,   cereals,  jellies,  broths 

thickened  with  cereals  or  farinaceous  flours. 
Drinks. 

Water,   mineral  waters,   lemonade,   orangeade,   grape-juice,   Im- 
perial drinks,  freely. 

Bowels. 

In  the  beginning. 

Calomel  gr.  iii  to  gr.  v  (0.20-0.30  Gm.)  or  in  divided  doses,  fol- 
lowed by  a  salt,  Epsom  or  Rochelle,  gss.-gi  (15-30  Gm.)  or  a  salt 
may  be  given  alone. 
Throughout  the  disease  constipation  is  the  rule. 

Calomel. 

Citrate  of  magnesia. 

Hunyadi  water. 

Cascara,  e.  g.,  fluid  extract  m.  xv  to  m.  xlv  (1-3  c.c.)  in  water. 

Compound  licorice  powder,  3ss.  to  3ii  (2-8  Gm.)  given  in  water. 

Aloin,  gr.  ss.  to  gr.  i  (0.030-0.060  Gm.). 


662  TREATMENT  OF  ACUTE  INFECTIOUS  DISEASES 

Retention  of  urine. 

Hot  fomentations  to  epigastrium. 

(For  technique,  see  Typhoid  Fever,  Chap.  XIV.) 

Sound  of  running  water. 

Catheterize. 

Specific  treatment. 
(See  text.) 

Treatment  of  symptoms. 

Pain  and  neuralgias. 
Ice-bag  to  head  for  headache. 

Fomentations  to  back  and  joints  or  mustard  plasters. 
Poultices. 

Chloroform  liniment. 

Methyl  salicylate  and  menthol  15  per  cent,  in  vaseline. 
Acetylsalicylic  acid  (Aspirin),  gr.  x  to  gr.  xv  (0.60-1  Gm.)  every 

two  hours. 
Acetphenetidin  (Phenacetin),  gr.  iv  to  gr.  viii  (0.25-0.50  Gm.) 

every  two  hours. 

Acetanilid,  gr.  ii  to  gr.  iv  (0.120-0.25  Gm.)  every  two  hours. 
Very  severe. 

Morphine  sulphate,  gr.  1/8  to  gr.  1/4  (0.008-0.015  Gm.). 
Fever. 

Cold  water,  sponges,  packs,  baths. 
(For  technique  of  bath,  see  Typhoid  Fever,  Chap.  XIV.) 
Vomiting. 

Cracked  ice  to  suck. 

Mustard  paste  to  epigastrium. 

(For  technique,  see  index.) 

Bismuth  subnitrate,  gr.  xv  to  gr.  xxx  (1-2  Gm.). 

Sodium  bicarbonate  gr.  x  to  gr.  xv  (0.60-1  Gm.). 

Cerium  oxalate  gr.  v  to  gr.  x  (0.30-0.60  Gm.)  or  combination  of 

above  drugs. 
Very  severe. 

Cocaine  hydrochloride  gr.  1/5  (0.012  Gm.) . 
If  exhaustion  threatens. 

Morphine  sulphate,  gr.  1/8  to  gr.  1/4  (0.008-0.015  Gm.)  hypoder- 

mically. 
Sleeplessness. 

Bromides,  gr.  xxx  (2  Gm.)  in  water  in  early  evening. 
Trional,  gr.  x  to  gr.  xx  in  warm  water,  in  whiskey,  in  powder. 
Chloralamid,  gr.  xv  to  gr.  xxx  (1-2  Gm.)  in  cold  water,  in  whiskey 

or  in  powder. 
If  more  resistant. 

Chloral,  gr.  x  to  gr.  xv  (0.65-1  Gm.)  in  water. 

Morphine  sulphate,  gr.  1/8  (0.008  Gm.)  hypodermically. 
Toxemia. 
Circulation. 

(See  Pneumonia,  Chap.  IX.) 


MALTA  FEVER  663 

Complication. 

Orchitis. 

(See  Parotitis,  Chap.  XXIII.) 

Convalescence. 

Fresh  air. 
Good  food. 
Iron. 
Arsenic. 

Prophylaxis. 

Elimination  of  infected  goats. 

Herds  tested. 

Milk  should  not  be  drunk. 

Instruction  in  regard  to  the  infectivity  of  milk,  urine  and  feces  of 

infected  goats. 

Care  of  the  water  and  food  supply. 
Disinfection  of  patient's  excretions. 
Screen  room  of  patient  against  insects. 


CHAPTER  XXXIII 

ROCKY  MOUNTAIN  SPOTTED  FEVER 

(TICK  FEVER  OF  THE  ROCKY  MOUNTAINS) 

THIS  disease  as  the  name  would  indicate  pervades  the  Rocky  Mountain 
Districts,  including  the  States  of  Washington,  Oregon,  California,  Ne- 
vada, Idaho,  Utah,  Montana,  Virginia  and  Colorado.  It  has  been 
characterized  as  an  "  acute,  endemic,  non-contagious,  but  probably 
infectious,  febrile  disease,  characterized  clinically  by  a  continuous 
moderately  high  fever,  severe  arthritic  and  muscular  pains  and  a  profuse 
petechial  or  purpural  eruption  in  the  skin,  appearing  first  on  the  ankles, 
wrists  and  forehead,  but  rapidly  spreading  to  all  parts  of  the  body" 
(Maxey).  It  is  transmitted  by  a  tick,  Dermacentor  venustus  (Derma- 
centor  andersoni).  The  virus  with  which  the  tick  becomes  infected  is 
entertained  by  certain  rodents  on  which  they  feed,  chipmunks,  ground 
squirrels,  mountain  rats. 

The  virus  will  not  pass  through  a  Berkfeld  filter  and  for  a  time  was 
believed  to  be  bacterial,  but  Wolback  has  isolated  a  micro-organism 
which  he  believes  to  be  a  parasite  of  a  different  nature.  He  can  identify 
it  neither  as  a  bacterium  nor  protozoon.  He  proposes  for  this  causative 
agent  of  Rocky  Mountain  Spotted  Fever  the  term  Dermacentroxenus 
rickettsi  in  honor  of  Rickett's  pioneer  work  in  this  disease.  This  virus 
was  shown  to  be  transmitted  hereditarily  in  ticks. 

It  occurs  almost  wholly  in  the  Spring  and  is  at  its  height  in  May  or 
June.  This  corresponds  exactly  with  the  period  of  activity  in  the  life 
history  of  the  tick. 

The  incubation  period  is  usually  4  to  6  days,  the  extreme  limit  being 
3  to  12  days.  It  requires  on  an  average  10  hours  of  feeding  time  for  the 
tick  to  infect. 

Symptomatology.  The  onset  is  abrupt  with  a  chill  though  the  chill 
may  be  preceded  by  a  few  days  of  malaise  and  it  has  been  noted  that 
when  such  is  the  case  as  in  most  instances  in  Idaho,  the  disease  is  less 
fatal. 

The  discomfort  suggests  a  grip  attack  with  severe  pain  in  bones, 
joints  and  muscles,  small  of  back  and  head;  a  little  dry  cough  and  photo- 
phobia are  common  and  epistaxis  occasionally.  The  temperature  rises 
fairly  quickly,  reaching  102°  to  104°  F.  on  the  second  day  and  continues 


ROCKY  MOUNTAIN  SPOTTED  FEVER  665 

to  104°  to  105°  F.  and  in  exceptional  instances  106°  F.  and  107°  F.  in  the 
second  week  and  it  begins  to  fall  by  lysis  toward  the  end  of  the  second 
week  and  strikes  normal  at  the  end  of  the  third. 

The  pulse  at  first  is  not  very  rapid,  but  later  increases  out  of  propor- 
tion to  the  temperature,  i.  e.,  a  pulse  of  120  to  102°  F.  of  fever  is  common. 
In  the  more  severe  cases  the  pulse  increases  and  signifies  a  bad  outlook. 
The  spleen  is  enlarged  and  palpable  early  in  the  disease.  The  rash  usu- 
ally appears  on  the  third  day,  but  varies  between  the  second  and 
seventh.  It  is  noted  first  on  the  wrist,  ankles,  back,  forehead,  arms,  legs, 
chest  and  lastly  abdomen.  It  is  well  out  in  24  to  36  hours  after  appear- 
ance; but  later  it  may  appear  on  palms  and  soles  and  the  mucous  mem- 
brane of  the  propharynx.  The  rash  at  first  is  a  rose-colored  macule 
disappearing  on  pressure,  but  gradually  it  darkens  to  a  purple  and  at  the 
end  of  a  week  fails  to  disappear  on  pressure.  It  then  tends  to  become 
petechial  and  considerable  subcutaneous  hemorrhages  may  be  seen. 
Often  the  rash  is  confluent.  It  begins  to  disappear  as  the  fever  begins  to 
go  down,  but  often  remains  for  some  time  as  pigmented  spots.  When 
remaining  discrete  this  pigmentation  has  been  likened  to  the  markings 
on  a  turkey  egg. 

In  severe  cases,  owing  to  occlusion  of  the  vessels  of  the  skin,  necrosis 
of  the  skin  of  the  fingers,  toes,  prepuce,  scrotum,  lobes  of  ears,  or  of  the 
soft  palate  may  occur.  A  general  desquamation  follows  the  subsidence  of 
the  rash.  Restlessness,  sleeplessness,  stupor  are  common  and,  in  severe 
cases,  delirium  and  coma  before  death.  Even  convulsions  have  been 
reported. 

Constipation  is  the  rule,  vomiting  in  severe  cases  and  slight  jaundice 
in  the  second  week. 

The  blood  shows  a  slight  leucocytosis  and  a  noticeable  increase  in  the 
large  mononuclears. 

One  attack  appears  to  confer  permanent  immunity.  The  mortality 
varies  in  different  localities.  In  Montana,  in  the  Bitter  Root  Valley,  it 
has  run  above  70  per  cent.,  in  Idaho  about  5  per  cent.  Outside  of  the 
Bitter  Root  Valley  it  runs  between  7  per  cent,  and  13  per  cent. 

This  disease  has  many  points  of  resemblance  to  Typhus  Fever. 

Treatment.  These  cases  occur  in  localities  where  all  the  niceties 
of  nursing  are  difficult  of  attainment  and  in  environments  where  the 
most  must  be  made  of  what  is  at  hand.  The  disease  runs  a  rather  long 
course  and  is  rife  with  discomforts  and  in  some  localities  almost  uni- 
versally accompanied  by  a  high  and  dangerous  degree  of  toxicity. 

The  coolest,  best  ventilated  room  should  be  chosen  or  the  case  may  be 
treated  in  the  open  air,  if  shade  and  protection  can  be  afforded.  So  far 
as  possible,  the  choice  of  the  bed,  its  care,  the  care  of  the  body,  baths, 


666  TREATMENT  OF  ACUTE  INFECTIOUS  DISEASES 

care  of  mouth,  nose,  eyes,  skin  and  genital^  should  be  carried  out  as 
directed  under  Typhoid  Fever  (Chapter  XIV);  the  only  danger  of 
infection  being  through  the  bite  of  the  tick,  the  disposition  of  excretions 
and  the  precautions  in  handling  the  patient  insisted  on  in  Typhoid  Fever 
need  not  be  observed  beyond  the  usual  rules  of  sanitation  and  clean- 
liness. 

Diet.  As  there  is  not  much  gastro-intestinal  disturbance  after  the 
onset  and  as  the  course  is  prolonged,  an  abundant  dietary  would  seem 
indicated  and  the  diet  advised  for  Typhoid  Fever  would  seem  logical. 
Water,  alkaline  drinks  and  fruit  juices  should  be  liberally  administered. 

The  Bowels.  An  initial  cathartic  may  be  given  of  castor  oil  5  ss.-5  i 
(15  to  30  c.c.)  or  of  a  salt,  Epsom,  Rochelle  or  Glauber's  5ss.  to  5i  (15  to 
20  grams)  which  may  or  may  not  be  preceded  by  calomel  gr.  iss.  to  ii 
(0.066-0.120  Gm.),  better  in  divided  doses,  especially  if  there  is  nausea 
and  vomiting.  One  gives  gr.  1/4  (0.015  Gm.)  every  1/4  of  an  hour  until 
the  above  dose  is  completed.  For  the  discomforts,  aches  and  pain 
aspirin  in  10  grain  doses  (0.66  Gm.)  at  2  or  3  hours  intervals  may  be  used 
or  very  small  doses  of  acetanilid  gr.  iss.  combined  with  bicarbonate  of 
soda  gr.  i  (0.06  Gm.)  and  citrated  caffeine  gr.  ss.  (0.03  Gm.)  at  half  hour 
intervals  until  6  doses  are  taken,  then  every  two  hours,  but  this  should  be 
only  in  the  early  stages  and  never  when  the  circulation  is  impaired.  If 
pains  are  intense  it  is  better  to  use  codeine  phosphate  gr.  1/8  to  gr.  1/2 
(0.008  to  0.03  Gm.)  at  2  to  4  hour  intervals.  The  drug  is  more  potent 
administered  hypodennically.  In  the  worst  cases,  and  especially  if  sleep 
is  lost,  morphine  sulphate  should  be  used  gr.  1/8  to  gr.  1/4  (0.008  to  0.015 
Gm.)  hypodennically.  Headache  is  relieved  by  the  above  measures  and 
an  ice-bag  (see  Pneumonia,  Chap.  IX)  may  be  applied  to  the  head. 

Fever.  Unless  very  high  or  long  sustained  had  better  be  left  alone. 
Cool  sponges  afford  relief  and  are  a  tonic  to  the  general  nervous  system. 
Antipyretics  should  not  be  used,  for  they  are  for  the  most  part  depres- 
sants to  the  circulation.  Excessive  temperatures  may  be  controlled  by 
cold  sponges  or  cold  baths,  such  as  the  slush  baths  and  the  cold  pack. 
(See  Typhoid  Fever,  Chap.  XIV  and  Scarlet  Fever,  Chap.  XVII.) 

Insomnia.  The  exhaustion  that  ensues  upon  loss  of  sleep  cannot  be 
overemphasized.  If  sleeplessness  is  due  to  pains  and  discomforts  or 
exhaustion  is  threatening  there  is  no  use  of  temporizing  with  milder 
hypnotics.  Morphine  sulphate  should  be  used  hypodennically  in  doses 
of  gr.  1/8  (0.008  Gm.),  to  be  repeated  if  necessary.  If  there  is  delirium 
begin  with  morphine  sulphate  gr.  1/4  (0.015  Gm.).  For  milder  cases 
one  may  use  bromides  in  doses  of  gr.  xv-gr.  xxx  (1-2  Gm.)  either 
potassium  bromide  or  the  mixed,  sodium,  ammonium  and  potassium 
salts.  Give  in  a  glass  of  water  in  the  early  evening  or  trional  in  doses  of 


ROCKY  MOUNTAIN  SPOTTED  FEVER  667 

gr.  v  to  xv  (0.33-1  Gm.)  or  chloralamid  gr.  xx-xxx  ((1.33  to  2  Gm.). 
Delirium  indicates  the  use  of  morphine  as  specified  above  and  hyoscine 
hydrobromide  gr.  1/200  to  gr.  1/150  (0.0003-0.00045  Gm.)  may  be  used 
with  caution,  for  it  is  a  depressant.  An  ice-bag  to  the  head  and  cool 
sponges  are  helpful.  The  circulation  should  receive  serious  attention.  It 
is  well  to  digitalize  the  heart  early  to  anticipate  a  depression  that  may 
steal  on  us  unawares.  For  the  procedure  consult  the  chapters  on  pneu- 
monia or  influenza.  In  urgent  cases  the  digitalization  should  be  as  rapid 
as  in  those  diseases,  but  in  more  moderate  cases  more  time  may  be 
taken  to  attain  digitalization  and  then  the  dose  may  be  dropped  to 
gr.  iii  to  gr.  iss.  (0.20  to  0.10  Gm.)  a  day.  (See  Pneumonia  and  Epidemic 
Influenza,  Chaps.  IX  and  XII). 

Emergency  cases  must  be  treated  with  intramuscular  or  intravenous 
administration  of  strophanthin.  (See  Pneumonia,  Chap.  IX.) 

There  is  no  specific  treatment 

Immune  serum  has  been  tried  without  result.  A  great  variety 
of  drugs  have  been  advocated  but  without  any  perceptible  beneficial 
effects.  Midrie  and  Parsons  as  the  result  of  experimental  work  on 
guinea  pigs  have  recommended  the  use  of  5  per  cent,  sodium  citrate  solu- 
tion intravenously  in  doses  of  60  c.c.  (3ii)  twice  a  day. 

Complications.  Pneumonia  is  an  infrequent  complication  and  is  to 
be  treated  as  under  other  circumstances. 

Prophylaxis.  The  knowledge  that  the  disease  is  always  conveyed 
by  the  tick  and  that  it  takes  the  tick  an  hour  or  more  to  become  attached 
to  and  feed  upon  the  host,  makes  a  systematic  search  for  ticks  on  the 
person  after  exposure  a  very  important  prophylactic  measure. 

SUMMARY 

Treatment 

Coolest  and  best  ventilated  room  or 

Treat  in  open  air. 

For  care  of  the  body,  mouth,  nose,  skin.     (See  Typhoid  Fever,  Chap.. 


Diet. 

Abundant,  if  disease  is  protracted.    (See  Typhoid  Fever,  Chap.  XIV.J 

Fluids. 

To  be  given  in  abundance.    (See  Typhoid  Fever,  Chap.  XIV.) 

Bowels. 

Initial  cathartic  of  castor  oil,  5ss.  to  5i  (15-30  c.c.)  or 
A  salt,  Epsom,  Glauber's  or  Rochelle  (15-20  Gm.). 


668'         TREATMENT  OF  ACUTE  INFECTIOUS  DISEASES 

May  or  may  not  be  preceded  by  calomel,^  gr.  iss.  to  ii  (0.060-0.120 
Gm.).    Better  given  in  divided  doses  especially  if  there  is  nausea. 

Aches  and  pains. 

Acetyl  salicylic  acid,  gr.  10  (0.66  Gm.)  at  2  to  3  hour  intervals  or 

Acetanilid,  gr.  iss.  (0.10  Gm.)  combined  with  sodium  bicarbonate 
gr.  i  (0.06  Gm.)  and  citrated  caffeine,  gr.  ss.  (0.03  Gm.)  at  half- 
hour  intervals  until  6  doses  are  taken  and  then  every  two  hours. 
Take  only  in  early  stages  and  never  if  circulation  is  impaired  or 

Codeine  phosphate  gr.  1/8  to  gr.  1/2  (0.008  to  0.03  Gm.)  at  two  to 
four  hour  intervals  or 

Morphine  sulphate,  gr.  1/4-1/8  (0.008  to  0.015  Gm.). 

Headache. 

May  be  relieved  by  above  measures  or  ice-bag.    (For  technique,  see 
Pneumonia,  Chap.  IX.) 

Fever. 

Give  no  drugs. 

Let  alone  unless  high  or  long  sustained. 

Cool  sponges  for  relief. 

Excessive  temperatures  use  cold  sponges,  cold  baths— ^-such  as  slush 

baths  and  cold  pack.     (For  technique,  see  Typhoid  Fever,  and 

Scarlet  Fever,  Chaps.  XIV  and  XVII.) 

Insomnia. 
If  due  to  pain  or  exhaustion,  morphine  sulphate  hypodermically, 

gr.  1/8-1/4  (0.008-0.015  Gm.). 
Repeat  if  necessary. 

Insomnia  with  delirium. 
Morphine  sulphate,  gr.  1/4  (0.0015  Gm.)  hypodermically. 

Less  urgent  insomnia. 
Bromides,  gr.  xv-xxx  (1-2  Gm.). 
Trional,  gr.  v-xv  (0.33-1  Gm.). 
Chloralamid,  gr.  xx-xxx  (1.33-2.  Gm.). 

Delirium. 

Morphine  as  above. 

Hyoscine  hydrobromide,  gr.  1/200-1/150  (0.0003-0.0045  Gm.). 

Ice-bag  to  head. 

Cool  sponges. 

Circulation. 

Well  to  digitalize  the  heart  early.    (See  Pneumonia,  Chap.  IX.) 
In  urgent  cases  rapid  digitalization.    (See  Pneumonia,  Chap.  IX.) 
Emergency  cases. 

Strophanthin  intramuscularly  or  intravenously.     (See  Pneumonia, 
Chap.  IX.) 


ROCKY  MOUNTAIN  SPOTTED  FEVER  669 

Specific  Treatment. 
Immune  serum  has  been  tried  without  results. 

Complications. 
Pneumonia  infrequent.    (See  Pneumonia,  Chap.  IX.) 

Prophylaxis. 
Search  for  the  tick  after  exposure  in  tick-infected  localities. 


CHAPTER  XXXIV 

LEPROSY 

To  no  other  unfortunate  has  the  term  "  unclean "  clung  through- 
out the  ages  so  insistently  as  to  the  leper. 

Its  importance  to  us  is  that  Leprosy  has  invaded  North  America  and 
while  its  distribution  is  not  so  uniform  as  is  the  case  with  most  of  the  in- 
fectious diseases,  still  its  distribution  is  no  respecter  of  climate  and  in  our 
own  country  it  is  found  in  Minnesota  in  the  North  and  Louisiana  in  the 
South,  just  as  abroad  it  finds  residence  in  the  cold  of  Norway  and  the 
heart  of  India.  Fortunately  in  this  country  the  numbers  are  not  large 
nor  the  spread  rapid,  still  its  mutilations  carry  no  less  horror  to-day  than 
in  biblical  times,  even  though  more  knowledge  protects  the  community 
from  unreasoning  fear  and  the  unfortunate  from  ill-usage.  At  least  we 
have  fixed  the  cause  in  a  definite  organism,  the  bacillus  leprae  and  learned 
something  of  its  habits1  and  the  present  time  is  witnessing  no  incon- 
siderable impulse  to  investigation  in  this  field  among  our  own  workers. 

Three  facts  of  practical  importance  about  bacillus  leprse  are,  first, 
that  in  all  possibility  its  portal  of  entry  into  the  human  organism  is  the 
naso-pharynx,  second,  that  it  is  discharged  by  way  of  all  the  secretions 
including  discharges  from  sores,  and  thirdly,  that  it  is  peculiarly  tena- 
cious of  life  even  in  an  adverse  environment. 

The  organisms  infect  all  the  organs  and  tissues  but  have  a  peculiar 
predilection  for  the  skin  and  peripheral  nerves  and  the  clinical  picture 
depends  on  which  of  these  structures  is  predominatingly  affected. 

Isolation.  The  isolation  of  the  leper  has  been  throughout  the  ages 
the  fruit  of  experience  and  recent  pleas  to  free  the  leper  in  the  com- 
munity meet  with  prompt  rebuttal  in  facts  educed  by  a  study  of  his  dis- 
tribution of  the  infecting  germs. 

Colonization  is  the  modern  method  of  isolation;  a  colonization  directed 
by  every  humane  effort  to  relieve  this  life-long  divorcement  from  the 
world. 

Precautions  of  Attendants.  It  is  essential  for  all  who  come  in 
contact  with  the  patients  to  know  that  the  bacilli  of  leprosy  have  been 
found  in  all  the  secretions,  urine,  feces,  sweat,  milk,  sputum,  in  the 
secretions  from  the  nose,  the  vagina,  the  urethra,  as  well  as  in  the  secre- 

1  Strong  in  Forchheimer's  Therapeusis  of  Internal  Diseases  would  imply  that 
identification  of  the  organism  of  Leprosy  is  by  no  means  certain. 


LEPROSY  671 

tions  and  pus  of  sores  and  that  all  these  secretions  should  be  destroyed  by 
burning  or,  when  contaminating  useful  articles,  by  boiling  or  by  powerful 
antiseptics.  It  should  be  particularly  remembered  that  the  lesions  are 
apt  to  be  early  and  severe  in  the  upper  air  passages  and  that  this  may  be 
conveyed  by  the  spray  of  a  sneeze  or  a  cough  or  even  in  talking.  Again  it 
is  to  be  remembered  that  the  bacilli  are  peculiarly  insistent  and  will 
remain  virulent  for  months  in  dried  secretions  and  in  soiled  linen. 

It  must  be  borne  in  mind,  too,  that  insects  may  be  the  means  of  con- 
veying infection  and  that  non-infected  animals  may  become  carriers. 
That  the  disease  is  not  highly  infectious  is  shown  by  the  fact  that  long 
contact  with  infected  persons  seems  necessary  for  its  conveyance. 

Cleanliness  of  the  skin,  the  mouth  and  nose,  sufficiency  of  good, 
well-cooked  food  and,  in  short,  careful  consideration  of  the  rules  of 
health  are  doubly  important  to  those  exposed  to  the  disease. 

Leprosy  is  a  curable  disease  and  that  always  means  that  it  is  the 
body's  own  forces  that  must  be  called  upon.  This  knowledge  accentuates 
the  importance  of  diet  and  hygiene,  measures  that  contribute  to  the 
body's  efficiency. 

The  fight  is  a  long  one  and  the  improvement  slow,  in  this  respect  like 
tuberculosis;  and  so,  as  in  the  latter  disease,  all  efforts  in  the  patient's 
behalf  must  be  persistent. 

Diet.  After  all  it  is  from  the  food  that  all  the  energy  used  by 
the  body  must  come,  for  the  production  of  immune  bodies  as  well  as 
for  other  purposes;  consequently,  it  should  be  abundant,  well  selected  as 
to  quality  and  well  prepared. 

Fresh  Air.  The  life  of  the  leper  like  that  of  the  tubercular  should 
practically  be  in  the  open,  the  same  provision  being  made  for  sleeping 
out  of  doors. 

Baths.  Cleanliness  is  most  important  and  baths  not  only  keep  the 
pores  of  the  skin  open  and  subserve  the  functions  of  that  structure,  but 
they  have  a  tonic  effect  on  the  nervous  system  and,  when  the  lesions  of 
the  skin  are  pronounced,  serve  as  a  vehicle  for  suitable  medication. 

Hot  baths  are  found  especially  grateful. 

Such  supportive  treatment  is  of  infinitely  greater  value  than  any 
empirics  or  specifics  that  we  have  at  our  command. 

Empirical  Treatment.  An  empiricism  means  merely  a  groping; 
the  drugs  that  find  favor  are  legion  and  none  very  satisfactory.  Of 
all  the  drugs  yet  employed  there  is  greater  agreement  on  the  value  of 
Chaulmoogra  oil  than  on  any  other. 

Chaulmoogra  Oil  (Oleum  gynocardiae).  This  oil  is  expressed  from 
the  seeds  of  the  gynocardia  odorata. 

Mode  of  Administration.     It  has  been  given  by  the  mouth,  by 


672          TREATMENT  OF  ACUTE  INFECTIOUS  DISEASES 

the  rectum,  hypodermically  and  applied  to  the  skin.  By  far  the  most 
common  method  is  by  the  mouth. 

Dosage.  The  amount  given  must  be  considerable  to  be  effective; 
but,  as  it  is  illy  borne  at  first  by  the  stomach,  the  initial  dose  should  be 
small  and  gradually  increased. 

It  is  well  to  begin  with  3  or  4  drops  at  a  dose  three  times  a  day 
and  increase  a  drop  or  two  to  the  dose  every  three  or  four  days  until  the 
limit  of  tolerance  is  reached  or  the  dose  totals  100  to  130  drops  three 
times  a  day.  The  limit  of  tolerance  is  determined  by  the  stomach's 
irritability. 

It  is  perhaps  better  given  before  meals,  using  as  vehicles  hot  coffee, 
hot  milk,  cordials  or  milk  of  magnesia  or  it  may  be  given  in  capsules  or  in 
pill-form,  although  the  administration  by  these  last  two  methods  would 
be  feasible  only  at  the  beginning. 

It  has  always  seemed  to  me  undesirable  to  give  a  disagreeable  or 
disagreeing  medicine  in  food,  lest  a  distaste  for  a  useful  food  be  acquired 
by  association. 

By  Rectum.  It  has  been  so  administered  in  milk  as  a  vehicle,  but 
this  would  scarcely  be  the  preferred  route. 

Hypodermically.  Some  irritation  may  ensue  from  the  oil  used  in 
this  manner,  but  when  sterilized  by  heat  this  is  said  to  be,  for  the 
most  part  or  quite,  avoided. 

The  oil  so  treated  as  to  lessen  its  irritating  qualities  has  been  brought 
forward  under  the  name  of  "anti-lepral." 

It  is  said  to  be  less  irritating  to  the  stomach.  As  much  as  5  c.c.  a  day 
for  months  has  been  tolerated  when  so  given.  These  are  also  supplied 
in  ampoules  of  from  1/2  to  1/5  mg. 

Externally.  Chaulmoogra  oil  diluted  to  5  per  cent,  to  10  per  cent, 
with  some  bland  oil  has  been  used  as  an  inunction. 

Two  rubbings  a  day  are  given.  Latham  and  English's  system  of 
treatment  gives  the  following  formula  for  its  local  use;  Chaulmoogra, 
4;  soft  paraffin,  6;  hard  paraffin,  1. 

There  can  be  no  doubt  that  the  rubbing  itself  would  be  beneficial 
to  the  infiltrated  or  anesthetic  skin,  but  as  compared  with  its  dose  by 
the  mouth  this  and  other  methods  are  of  dubious  value;  little  is  known  of 
its  modus  operandi  in  cases  which  improve,  beyond  the  fact  that  as  fat 
it  has  some  food  value. 

Local  Treatment.  Two  and  1/2  per  cent,  solution  of  benzoylchloride 
as  a  nasal  spray  and  an  application  to  leprous  ulcers  is  said  to  be  followed 
by  improvement  in  these  lesions,  but  one  may  have  to  have  recourse 
to  surgical  treatment. 

The  disadvantages  in  its  use  rest  upon  its  irritating  action  on  the 


LEPROSY  673 

gastrointestinal  canal  which  induce  vomiting  and  diarrhea.  This  seems 
not  difficult  to  avoid  if  care  be  taken  in  its  administration. 

Opinions  differ  about  its  value.  Dyer,  whose  experience  in  Louisiana, 
where  it  is  endemic,  gives  him  authority,  speaks  highly  of  it  in  Osier's 
Modern  Medicine,  and  reports  twelve  cures  in  his  own  experience  since 
1894.  Wooley  on  the  other  hand  grants  no  gain  to  its  use  and  believes 
improvement  due  to  a  better  appetite  and  better  functioning  of  the  skin 
following  its  use,  such  as  follow  certain  systems  of  baths. 

It  must  be  said,  however,  that  the  results  of  this  treatment  have 
made  a  considerable  impression  on  most  men  who  have  employed  it  and 
is  perhaps  the  best  weapon  at  hand  at  the  present  moment. 

Other  Drugs.  Among  other  drugs  of  less  repute  are  Nastin,  a 
bacterial  fat  which  is  diluted  in  benzoylchloride  to  lessen  its  irritative 
effects  to  the  strength  of  .05  per  cent.,  called  Nastin  B,  and  to  .2  per 
cent.  Nastin  B.2 

Bercovitz  reporting  from  China  on  the  method  advocated  by  Heisser, 
uses  hypodermically  a  mixture  of  this  formula 

Camphorated  oil 60  c.c.  5» 

Chaulmoogra  oil 60  c.c.  5  " 

Resorcin 4  grams.         gr.  Ix 

This  after  sterilization  is  injected  under  the  skin  of  the  arms  and  legs 
in  doses  of  1  c.c.  of  the  mixture,  weekly  for  three  doses,  then  gradually 
increase  to  3  c.c.  weekly.  There  was  always  a  slight  reaction  after  the 
first  dose,  causing  a  mild  headache  with  malaise  and  nausea. 

With  this  treatment  he  combined  a  bath  of  2  per  cent,  soda  bicarbo- 
nate taken  immediately  after  the  injection  three  times  a  week  and  fol- 
lowed by  complete  rest  for  a  half  hour  and  by  a  saline  cathartic  the  next 
morning,  and  a  compound  of  iron  and  arsenic.  Inside  of  four  weeks  he 
found  a  distinct  amelioration  in  all  patients  so  treated.  This  was  the 
more  noticeable  in  the  tubercular  type. 

One  c.c.  subcutaneously  once  a  week  for  five  or  six  weeks  is  used 
of  the  weaker  dilution,  then  is  followed  by  weekly  injections  of  the 
stronger.  This  has  its  advocates  but  elicits  no  such  commendation  as 
the  Chaulmoogra  oil. 

Calmette's  Serum.  Dyer  attracted  by  the  belief  among  cer- 
tain West  Indians  that  the  bite  of  certain  reptiles  cured  leprosy,  used 
Calmette's  Antivenomous  Serum  in  doses  of  5  c.c.  to  20  c.c.  under  the 
skin,  sometimes  as  often  as  every  day  and  found  excellent  results,  re- 
porting three  cures. 

Specific  Treatment.  Very  naturally  in  this  day  of  serum  and 
vaccine  therapy  efforts  have  been  made  to  utilize  the  products  of  bac- 


674  TREATMENT  OF  ACUTE  INFECTIOUS  DISEASES 

terial  action  to  enhance  the  production  of?immune  bodies,  and  as  a 
matter  of  course  there  have  been  many  disappointments.  Among  the 
later  efforts  and  one  giving  some  promise  is  a  toxin  derived  from  the 
bacillus  leprse  by  Rost  and  called  "leprolin." 

Its  use,  of  course,  attempts  an  active  immunization.  Its  dose  is 
10  c.c.  given  intravenously  at  two  to  three  day  intervals  and  further 
dosage  determined  as  in  the  use  of  tuberculin  or  vaccines,  by  the  reac- 
tions induced. 

It  is  said  to  be  contraindicated  in  the  presence  of  pulmonary  or  kidney 
complications. 

It  is  hardly  fair  as  yet  to  draw  conclusions,  but  judicial  clinicians 
seem  to  be  optimistically  inclined  toward  it. 

Tonic  Treatment.  More  or  less  emphasis  is  laid  on  the  value  of 
tonics;  and  strychnine  or  nux  vomica,  phosphates  and  iron  are  used  as 
in  other  conditions  which  are  believed  to  indicate  their  use. 

At  the  moment  of  the  revision  of  this  work  an  elaborate  study  of  the 
chemotherapeutics  of  Chaulmoogra  oil  by  Walter  and  Sweeney  appeared 
in  which  they  concluded  that  the  therapeutic  action  of  the  drug  was 
due  to  its  "direct  antiseptic  and  bactericidal  action  on  B.  leprse." 
They  suggest  that  the  oil  or  its  acid  esters  like  other  fats,  may  well  be 
stored  in  the  tissue  until  the  concentration  becomes  bactericidal. 

Surgical  Treatment.  It  is  important  to  evacuate  any  pus.  Sores 
and  mutilations  demand  the  removal  of  diseased  tissue  of  skin  or  bone. 
Amputations,  excision  of  nodules,  stretching  of  nerves  for  pain,  etc., 
may  be  necessary. 

X-Ray  treatment  is  said  to  reduce  the  size  of  the  tubercles. 

Prognosis.  So  evil  a  reputation  has  leprosy  borne  throughout 
all  history  that  the  impression  one  receives  of  the  prognosis  is  of  the 
worst;  and  yet  a  study  of  the  disease  shows  that  it  is  self -limited  at 
any  stage  and  that  a  mode  of  life  aimed  at  improving  the  general  health 
quickens  the  process  of  cure  more  than  anything  else  can  do. 

That  death  or  mutilation  is  the  final  issue  in  most  of  the  cases,  how- 
ever, is  all  too  true. 

Prophylaxis  to  the  community  consists  in  isolation;  to  the  indi- 
vidual in  avoidance  of  contact  with  the  secretions  and  discharges.  It 
has  long  been  noted  that  long  contact  seems  necessary  for  infection. 
Extremely  interesting  results  bearing  on  this  fact  have  followed  upon 
the  work  of  Duval  and  Gurd  on  animals.  I  quote  from  their  article: 
"Two  factors  are  of  great  importance  in  effecting  infection.  In  the 
first  place,  a  sufficiently  large  number  of  organisms  must  be  employed, 
and,  what  is  still  more  important,  second  and  subsequent  inoculations 
are  more  liable  to  produce  leprous  lesions  than  are  the  primary  injections. 


LEPROSY  675 

"Such  preliminary  doses,  whether  they  consist  of  living  or  dead 
organisms,  produce  a  condition  of  hypersensitiveness  or  allergy  which 
renders  it  possible  by  a  second  injection  of  viable  bacilli  to  induce  the 
development  of  a  reactionary  lesion.  Lesions  arising  as  the  result  of 
a  second  inoculation  develop  more  rapidly,  increase  in  size  more  quickly, 
and  persist  for  a  longer  period  than  those  taking  place  as  the  result  of  a 
single  inoculation,  even  though  very  large  doses  are  used.  Moreover, 
the  bacilli  in  these  lesions  are  more  liable  to  lead  to  metastasis  and  to  a 
generalized  infection.  We  regard  the  results  of  these  experiments  as 
having  considerable  bearing  upon  the  development  of  the  disease  in 
human  cases,  since  we  find  that  it  is  chiefly  among  those  living  in  pro- 
longed intimate  contact  with  leprous  patients  that  leprosy  develops." 
(Journal  of  Experimental  Medicine,  Aug.  1,  1911.) 

I  have  already  spoken  of  the  danger  to  those  in  contact  with  patients 
that  arise  from  secretions,  discharges  and  spraying  of  coughing,  sneezing, 
etc.,  and  how  these  secretions  should  be  disposed  of.  That  the  naso- 
pharynx is  probably  the  portal  of  entry  accentuates  the  precautions  that 
should  be  taken  not  to  carry  the  infection  by  the  hands  to  this  locality. 
The  possibility  of  infection  by  way  of  the  skin  by  minute  traumata  or 
bites  of  insects  must  not  be  forgotten. 

It  would  seem  almost  unnecessary  to  mention  the  dangers  attendant 
on  marriage,  and  the  precautions  that  should  be  taken  in  the  employment 
of  nurses,  wet  nurses  or  others  coming  into  close  contact  with  members 
of  a  household  who  live  in  an  area  where  leprosy  is  endemic. 

Another  fact  of  importance  is  the  remarkable  viability  of  the  bacilli 
leprse,  which  will  survive  for  months  or  years  in  a  locality  once  inhabited 
by  a  leper.  This  makes  disinfection  of  houses  and  articles  subjected  to 
contamination  doubly  imperative  and  demands  thoroughness.  It  also 
emphasizes  the  importance  of  colonization. 

The  dead  should  be  cremated;  for  the  leper  bacillus  has  been  found 
viable  months  after  burial. 

SUMMARY 

Isolation. 

By  colonization  the  common  method. 

All  secretions  and  excretions,  urine,  feces,  sweat,  milk,  sputum,  those 
from  the  nose,  vagina,  urethra,  all  contain  the  bacillus  and  should 
be  destroyed  by  fire  or  antiseptics.  (See  Typhoid  Fever,  Chap. 

Attendants  must  remember  that  the  spray  of  sneezing,  coughing 

and  talking  can  convey  the  organism. 
Insects  can  convey  infection. 
Attendants  must  give  especial  attention  to    their  personal  hygiene 


676  TREATMENT  OF  ACUTE  INFECTIOUS  DISEASES 

Diet. 

Must  be  sufficient. 

Fresh  air. 
Life  in  the  open;  sleep  in  open  air. 

Skin. 
Must  be  kept  clean  by  daily  baths. 

Empirical  treatment 

Chaulmoogra  oil. 
Dose. 

Three  or  four  drops  three  times  a  day.    Increase  a  drop  or  two 
every  three  to  four  days  until  100  to  130  drops  three  times 
a  day  are  given  or  until  irritability  of  the  stomach  prevents. 
May  be  given  in  hot  coffee,  cordials,  milk  of  magnesia,  hot 
milk,  capsules;  best  before  meals. 
Hypodermically. 
External  use. 
Under  sterile  precautions  give  hypodermic  injections  of: 


Camphorated  oil  ..........  .........  60  c.c. 

Chaulmoogra  oil  ...................  60  c.c. 

Resorcin  ...........................  4  Gm.        (gr.  Ix). 

M.  et  S.  1  c.c.  each  week  for  three  doses.  Increase  gradually  to  3  c.c. 
once  a  week. 

Follow  each  dose  immediately  by  a  bath  of  2  per  cent,  sodium 

bicarbonate. 

Rest  for  one-half  hour  after  bath. 

Follow  each  dose  by  a  saline  cathartic  the  next  morning. 
Duration  of  treatment  —  four  to  six  weeks.    (Bercovitz.) 
Other  drugs  and  measures. 

Nastin.  1    ,Q     ,     ,  >. 

Calmette's  Serum.  J  (See  tert') 

Specific  treatment. 
Leprolin,  10  c.c.  intravenously  every  two  to  three  days. 

Tonic  treatment. 

Strychnine  or  Nux  Vomica. 

Iron. 

Arsenic. 

Phosphates. 

Local  treatment. 

Two  and  one-half  per  cent,  solution  of  benzoylchloride  as  nasal  spray 
and  as  application  to  leprous  ulcers. 


LEPROSY  677 

Surgical  treatment.  }  ,0  ,  . 

„  _°  \  (See  text.) 

X-Ray  treatment.     J  v 

Prophylaxis. 
Isolation, 

Avoid  contact  with  secretions  and  discharges. 

Thorough  disinfection  of  all  objects  in  contact  with  a  case  of  leprosy. 
Dead  should  be  cremated. 


CHAPTER  XXXV 

ANTHRAX 

ANTHRAX  is  a  disease  that  affects  peculiarly  domestic  animals,  the 
horse,  cattle,  sheep  and  goats. 

Many  infected  hides  are  now  coming  into  the  country  from  epidemic 
centres  in  China,  India,  Africa,  South  America  and  more  cases  of  anthrax 
are  seen  than  before  the  recent  war.  An  investigation  of  the  shaving 
brush  industry  traced  the  source  of  infected  hair  not  only  to  points  out- 
side the  country,  but  to  Chicago  as  well. 

The  causative  agent  is  the  bacillus  anthracis,  a  large  spore-bearing 
organism,  and  the  first  shown  to  have  causative  relationship  to  an  in- 
fectious disease. 

The  disease  is  conveyed  to  man  through  contact  with  animals  or 
their  secretions. 

It  may  enter  and  infect  the  skin  through  minute  wounds  or  abra- 
sions, so  is  most  likely  to  occur  on  exposed  surfaces  and  in  individuals 
handling  the  sick  animals,  their  carcasses  or  hides,  wool  or  hair  such  as 
drovers,  farmers,  veterinarians,  butchers,  porters  of  hides,  wool  sorters, 
tanners,  etc. 

The  skin,  too,  may  be  inoculated  by  the  bite  of  the  stable-fly,  and  by 
the  use  of  the  shaving  brush. 

The  lesion  is  called  "malignant  pustule."  At  first  a  papule,  then 
vesicles  and  pustules,  soon  with  deep  and  extensive  involvement  of  the 
subjacent  and  adjacent  tissues,  appear.  Or  it  may  take  a  malignant 
edematous  type  in  which  pustules  may  be  absent  or  an  erysipelatous 
type,  difficult  to  differentiate  from  ordinary  facial  erysipelas  without 
bacterial  findings. 

The  external  form  begins  with  a  minute  red,  hard  pimple  at  the  site  of 
inoculation.  This  papule  becomes  a  vesicle  and  is  soon  surrounded  by 
an  area  of  edema;  the  vesicle  becomes  a  pustule,  turns  black  and  in  36 
hours  forms  a  black  eschar  that  gave  it  the  French  name  charbon.  The 
lymphatics  become  swollen  and  painful  in  3-4  days. 

Of  the  cutaneous  lesions  those  occurring  in  the  head  and  neck  region 
are  especially  dangerous  and  are  associated  with  extensive  edema.  The 
mortality  in  these  cases  is  given  at  40-45  per  cent,  against  12.5  per  cent, 
in  upper  extremities  and  1.2  per  cent,  in  trunk  and  lower  extremities. 

Characteristic  is  the  freedom  from  pain,  in  spite  of  the  extensive 


ANTHRAX  679 

infiltration.  Sooner  or  later,  depending  on  the  virulency,  the  symptoms 
of  general  infection  follow.  It  may  be  rapidly  fatal;  if  not  it  runs  a  course 
of  9  or  10  days.  Fortunately  the  tendency  of  the  disease  in  man  is  to 
remain  localized. 

On  the  other  hand  it  may  enter  the  body  through  the  air  passages 
or  by  way  of  the  mouth.  Infection  of  the  lungs  occurs  so  commonly 
among  one  class  of  workers  that  their  occupation  has  given  a  name  to 
the  disease,  the  "wool-sorter's  disease,"  due,- of  course,  to  inhalation  of 
spores  borne  in  the  dust  raised  by  their  work  in  the  wool. 

The  course  is  rapid ;  two,  three  or  four  days.  The  symptoms  point  to 
an  involvement  of  the  lungs  but  neither  subjective  nor  objective  signs 
are  characteristic.  Rapid  asthenia  sets  in,  followed  by  death. 

When  the  infection  is  by  way  of  the  mouth  the  intestine  is  affected. 

There  is  a  selective  action  on  the  lymphatics  resembling  that  in  ty- 
phoid fever.  The  inflammation  is  intense  with  edema  and  hemorrhagic 
extravasations  and  there  may  be  perforation  of  all  the  coats  with  sero- 
purulent  peritonitis. 

This  usually  occurs  through  eating  of  infected  and  improperly  cooked 
meat  or  drinking  infected  milk,  or  it  may  come  from  food  contaminated 
in  the  handling  or  from  the  patient's  hands.  It  may,  however,  localize 
in  the  intestine  by  the  blood  route.  This  form  is  rare  in  man.  It  is 
manifested  by  stormy  gastro-intestinal  symptoms  that  resemble  a  poi- 
soning or  may  simulate  intestinal  obstruction.  It  is  rapidly  fatal.  One 
speaks  of  it  as  "Intestinal  Anthrax."  Death  follows  in  two  to  six 
days. 

Treatment.  The  treatment  aims  at  supporting  the  patient's 
strength,  as  in  any  other  infection,  the  use  of  specific  remedies,  the 
treatment  of  the  local  lesion  and  the  relief  of  symptoms. 

As  it  is  only  the  external  form  of  infection  that  we  can  hope  to  attack 
with  success  and  that  only  when  seen  early,  we  will  begin  with  a  consid- 
eration of  the  local  treatment. 

Local  Treatment.  This  is  distinctly  a  surgical  problem.  It  would 
seem  to  me  that  a  lesion  rife  with  such  fatal  possibilities  as  malignant 
pustule  should  have  the  most  radical  treatment  and  that  complete  ex- 
cision going  well  wide  of  the  lesion  out  into  the  sound  tissues  should  be 
practiced.1  It  is  universally  advised  that,  in  addition,  the  open  wound 
should  be  thoroughly  cauterized  with  phenol  (liquified  carbolic  acid)  or 
with  actual  cautery.  In  addition,  some  authors  advise  injections  of 
carbolic  acid  into  the  tissues  at  several  points  around  the  area  of  excision, 
as  the  bacilli  on  their  way  to  the  lymphatics  may  be  harbored  there.  It 

1  Carey  reports  a  cure  by  this  method  since  the  above  was  written.  A.  J.  M.  S., 
May,  1920,  Vol.  CLIX,  No.  5,  p.  742. 


680  TREATMENT  OF  ACUTE  INFECTIOUS  DISEASES 

may  be  used  in  3  per  cent,  watery  solution.  Others  prefer  liquified 
carbolic  acid  as  less  likely  to  be  absorbed  from  the  site  of  injection. 

There  seems  to  be  of  late  a  growing  preference  for  an  expectant  treat- 
ment over  excision,  using  bichloride  of  mercury  dressings,  boric  acid 
dressings,  or  alcohol  compresses  (70  per  cent.).  Gray  ointment  has 
found  some  favor.  Rest  to  the  part  affected  is  of  cardinal  importance. 

To  give  specific  direction  for  excision  I  cannot  do  better  than  borrow 
from  Dudley's  article  in  the  Journal  of  the  A.  M.  A.,  Jan.  5th,  '18. 

He  cleanses  the  lesion  thoroughly  with  soap  and  sterile  water, 
rinses  with  sterile  water,  paints  with  8  per  cent,  (or  stronger)  phenol 
"  (1  part  of  ordinary  carbolic  acid  to  12  parts  of  water) "  and  rinsed  with 
alcohol. 

He  then  paints  the  lesion  with  collodion  to  prevent  contamination 
of  the  line  of  incision. 

Following  this  preparation  of  the  pustule,  8  per  cent,  phenol  is  injected 
into  the  tissues  all  about  the  lesion  to  wall  off  the  infection.  This  re- 
quires usually  some  6  c.c.  One-quarter  inch  outside  the  phenolized  zone 
he  injects  5  to  6  syringefuls  of  25  per  cent,  alcohol  (6-10  c.c.)  These,  he 
says,  are  about  11/2  inches  outside  the  centre  of  the  lesion.  The  line  of 
incision  is  painted  with  8  per  cent,  phenol  solution  and  an  area  2  1/2- 
31/2  inches  in  diameter  excised.  After  the  excision  the  base  and  edges 
are  painted  with  pure  95  per  cent,  phenol  and  neutralized  at  once  with 
absolute  alcohol.  The  skin  is  cleansed  with  alcohol  and  a  wet  dressing 
then  is  applied  of  boric  acid  solution  2  to  4  per  cent.,  20  per  cent,  alcohol 
or  hypertonic  salt  solution. 

If  in  spite  of  this,  slight  edema  appears  at  the  angle  of  the  wound, 
further  steps  are  taken.  He  injects  3  to  4  syringefuls  (6-10  c.c.)  of 
8  per  cent,  phenol  into  the  edematous  tissue  and  if  this  fails  to  cure 
incises  freely  into  the  line  of  the  edema  and  puts  in  gauze  drains  and 
injects  more  8  per  cent,  phenol.  Finally  he  applies  an  ice-bag  to  the  area. 

Dr.  D.  F.  Dudley  in  a  personal  communication  says:  "I  have  come  to 
believe  that  excision  of  pustules  near  the  eye  or  nose  is  always  a  failure 
as  the  region  cannot  be  well  prepared  with  the  usual  strong  antiseptics 
and  since  a  large  amount  of  tissue  cannot  be  excised  in  these  locations. 
Lesions  about  the  eye  and  nose  should  be  walled  off  with  the  phenol 
solution  and  treated  by  serum;  incisions  in  the  edema  but  not  into  the 
pustule  may  be  made  later  if  necessary  and  phenol  solution  again  in- 
jected. I  am  now  preparing  a  paper  on  'The  Choice  of  Treatment' — 
this  is  necessary  because  of  difficulties  in  certain  locations  and  because 
I  have  found  that  the  age,  health,  presence  of  some  other  trouble  such 
as  heart,  lungs  or  high  blood  pressure  are  factors  to  be  considered  before 
taking  a  chance  either  on  serum  or  excision.  I  can't  emphasize  too 


ANTHRAX  681 

much  the  importance  of  choosing  the  cases  which  shall  be  excised  in- 
stead of  using  serum  and  vice  versa." 

At  Camp  Hancock,  Ludy  &  Rice  have  dissected  out  the  lesion  with  a 
nose  cautery  after  infiltrating  the  surrounding  tissue  with  30-50  c.c. 
of  anti-anthrax  serum.  The  line  of  incision  should  go  at  least  1/2  inch 
from  the  border.  They  dress  the  wound  over  in  24  hours  with  a  solution 
of  phenol  3  parts;  camphor  7  parts;  glycerin  40  parts;  and  alcohol  180 
parts. 

At  Guy's  Hospital,  following  excision,  ipecac  has  been  sprinkled  on  the 
wound  and  has  been  administered  at  the  same  time  internally. 

Carbolic  Acid.  Carbolic  acid  has  been  used,  too,  around  the  site 
of  the  infection  and  as  originally  recommended,  as  often  as  every 
hour  or  even  more  frequently,  10  to  15  minims  of  the  3  per  cent,  watery 
solution  or  even  the  liquified  phenol. 

Hot  poultices  are  applied  to  the  infected  area. 

Bloodgood  and  McGlannan  favor  this  treatment  when  excision  will 
result  in  much  mutilation. 

In  one  case  successfully  treated  with  antitoxin,  the  local  treatment 
consisted  only  of  soaking  in  hot  bichloride  solution  and  the  application 
of  a  Bier  bandage. 

As  another  caustic,  caustic  potash  has  been  recommended. 

The  wound  is  dressed  with  a  wet  dressing. 

Specific  Treatment.  Serum  from  immunized  sheep  or  asses  has 
been  used  in  the  treatment  of  animals  and  more  lately  of  man.  In 
the  cases  reported  30  to  80  c.c.  of  the  serum  was  used  daily  both  intra- 
venously and  subcutaneously. 

One  should  favor  liberal  doses. 

Ludy  and  Rice  give  75  c.c.  of  anti-anthrax  serum  with  50  c.c.  of 
physiological  sodium  chloride  solution  intravenously  and  75  c.c.  of  the 
serum  intramuscularly.  The  serum  is  repeated  every  8  hours,  if  needed. 
Dudley,  using  the  serum  furnished  by  the  U.  S.  Bureau  of  Animal 
Industry  gives  35  c.c.  intravenously  for  the  first  dose,  followed  in  8  to 
16  hours  by  a  second  intramuscularly  or  intravenously;  this  is  repeated 
if  necessary. 

Raj  an  continued  local  treatment  with  intramuscular — some  50  c.c.  at 
first,  somewhat  smaller  doses  on  such  succeeding  days  as  serum  is  in- 
dicated. 

At  Bellevue  in  some  of  the  cases  40  c.c.  of  serum  was  given  into  the 
vein  every  four  hours  and  into  the  tissues  about  the  pustule  about  10 
c.c.  in  multiple  punctures  of  1/2  to  1  c.c.  each,  thus  thoroughly  infil- 
trating them,  at  4-hour  intervals.  This  seemed  fairly  effectual. 

The  serum  may  be  obtained  from  the  Department  of  Agriculture. 


682  TREATMENT  OF  ACUTE  INFECTIOUS  DISEASES 

The  specific  serum  should  be  injected  about  the  pustule  or  if  excised 
in  the  adjacent  area.  One  uses  an  antitoxin  needle  and  syringe.  The 
needle  is  inserted  just  outside  the  margin  of  the  lesion  and  directed 
toward  the  subcutaneous  tissue  at  the  base  of  the  eschar,  using  10  to 
15  c.c.  of  the  serum.  This  is  done,  of  course,  with  intravenous  and 
intramuscular  administration  of  the  serum. 

The  general  mortality  in  a  considerable  series  not  receiving  serum 
was  given  as  27  per  cent.,  but  may  be  very  much  higher  in  individual 
series. 

The  results  reported  certainly  make  the  use  of  the  serum  impera- 
tive. The  mortality  has  been  lowered  to  6  per  cent,  or  less  by  the  use 
of  serum. 

There  has  been  much  controversy  as  to  what  constitutes  the  specific- 
ity of  the  serum.  By  some  it  is  maintained  that  the  results  are  due 
merely  to  the  reaction  provoked  by  any  foreign  protein,  provocation 
of  leucocytosis,  possibly  a  mobilization  of  ferments,  the  phenomena  of 
the  so-called  shock  therapy;  for  this  reason,  other  non-specific  sera 
have  been  advocated,  especially  normal  beef  serum,  which  seems  to  be 
less  likely  to  provoke  disagreeable  reactions  than  horse  serum.  The 
methods  have  been  by  hypodermic  injection  or  in  severe  cases  or  septi- 
cemic  cases  intravenously.  The  dose  is  10-30  c.c.  or  more. 

I  should  incline  to  more  liberal  dosage,  as  the  amount  administered 
does  not  determine  toxicity,  and  to  frequent  administrations,  daily  or 
oftener  in  severe  cases. 

The  reaction  will  be  a  sharp  rise  in  temperature,  leucocytosis,  then 
a  fairly  prompt  fall  of  temperature  below  the  level  determined  before 
the  injection,  with  an  improvement  in  symptoms  general  and  local. 
(Hyman  &  Levy.) 

Graham  and  Detweiler  in  one  successful  case  of  septicemia,  with 
recovery  of  the  organism  from  the  blood,  made  use  of  chloramin-T 
(Dakin)  intravenously  with  the  serum.  They  used  100  c.c.  of  the 
chloramin-T  and  80  c.c.  of  the  serum.  They  attributed  much  of  the 
good  results  to  the  use  of  the  chloramin-T.  I  have  had  no  personal 
experience  with  this  method. 

See  Jour.  Am.  Med.  Asso.,  Mar.  9,  1918,  p.  671,  Vol.  70,  No.  10. 

When  constitutional  symptoms  are  manifest,  as  they  are  from  the 
beginning  in  internal  anthrax  and  as  they  are  after  a  greater  or  less 
period  in  malignant  pustule,  supportive  treatment  should  be  vigor- 
ously begun. 

This,  of  course,  means  rest  in  bed  in  a  room  chosen  with  a  view 
to  convenience  and  ventilation  and  one  where  isolation  may  be  main- 
tained. 


ANTHRAX  683 

If  this  room  is  accessible  to  porch,  verandah,  or  lawn,  where  open-air 
treatment  may  be  maintained,  it  is  a  distinct  advantage. 

The  body  should  have  proper  attention,  such  as  baths  for  cleanli- 
ness, care  of  mouth,  nose,  genitals,  attention  to  pressure  points,  in 
other  words  all  that  pertains  to  good  nursing.  (See  Typhoid  Fever 
or  Pneumonia.) 

Especial  attention  should  be  given  to  the  destruction  of  discharges 
from  the  pustules  and  the  secretions  and  the  excretions  of  the  body, 
which  contain  the  anthrax  bacilli. 

The  diet  should  be  sufficient  and  based  on  the  same  considerations 
as  determine  the  dietary  in  other  acute  infections.  (See  Diet  in  Acute 
Febrile  Conditions,  Chap.  II.) 

The  severity  and  stormy  course  of  the  infection  in  internal  anthrax 
and  the  violence  of  gastro-intestinal  symptoms  in  the  intestinal  form 
of  anthrax,  will,  of  course,  modify  these  rules  considerably. 

Symptomatic  Treatment.  The  temperature  is  rarely  high  and 
requires  no  consideration,  per  se. 

Sooner  or  later  the  circulation  begins  to  wane  and  stimulation  be- 
comes necessary.  To  the  failure  of  vaso-motor  centers  such  drugs 
as  caffeine  or  camphor  are  directed,  in  doses  of  gr.  v  (0.33  Gm.)  at 
two  to  four  hour  intervals,  the  former  as  a  soluble  salt  of  sodium  sali- 
cylate  or  benzoate  and  the  latter  in  oil,  10  per  cent.  Both  are  used 
under  the  skin  or  better  still  into  the  muscle. 

Strychnine  may  also  be  used  in  doses  of  gr.  1/40  to  gr.  1/30  of  the 
sulphate  (0.0015-0.002  Gm.)  at  three  to  four  hour  intervals. 

To  support  the  heart,  digitalis  in  sufficient  doses,  gr.  ix  to  gr.  xii 
(0.6-0.8  Gm.)  a  day  of  the  leaf  or  its  equivalent  of  the  tincture  3iss. 
to  ii  (6-8  c.c.)  or  of  the  infusion  fresh  5iss.-ii  (45-60  c.c.)  until  results 
are  obtained  or  30  or  40  grains  have  been  given.  From  this  point  pro- 
ceed cautiously  with  3  to  6  grains  a  day. 

If  the  need  is  urgent  strophanthin  into  muscle  or  vein  gr.  1/120-gr. 
1/60  (mg.  1/2  to  1),  followed  by  digitalis. 

It  is  my  belief  that  in  the  circulatory  failure  of  any  acute  infectious 
disease  digitalis  or  strophanthin  is  far  more  valuable  than  any  of  the 
stimulants  named. 

Headache  may  be  relieved  by  the  ice-bag;  restlessness  and  sleep- 
lessness by  codeine  phosphate  gr.  1/4  to  gr.  ss.  (0.015-0.030  Gm.)  or  if 
severe,  by  morphine  sulphate  gr.  1/8  to  gr.  1/4  (0.008-0.015  Gm.).  In- 
somnia may  be  relieved  by  chloral  gr.  x  to  gr.  xv  (0.66-1  Gm.),  if  the 
circulation  is  not  impaired. 

Vomiting  will  require  cessation  of  food  or  small  quantities  of  liquid 
food,  cracked  ice,  sodium  bicarbonate  or  bismuth  subnitrate  in  gr.  x  to 


684  TREATMENT  OF  ACUTE  INFECTIOUS  DISEASES 

gr.  xv  (0.66V1  Gm.)  doses  or  oxalate  of  cerium  gr.  v  to  gr.  x  (0.33-0.66 
Gm.)  or  a  combination. 

Diarrhea  will  need  the  administration  of  large  doses  of  bismuth 
gr.  xxx  to  gr.  Ix  (2-4  Gm.)  every  two  hours,  or  opium  gr.  1/4  to  gr.  ss. 
(0.015-0.03  Gm.)  at  the  same  interval  or  starch  enema  with  opium 
as  tincture  m.  x  to  m.  xv  (0.66-1  c.c.). 

Delirium  will  demand  restraint,  the  use  of  morphine  or  chloral  in 
doses  given  or  hyoscine  hydrobromide  gr.  1/200  to  gr.  1/150  (0.00030- 
0.00045  Gm.). 

Convulsions  demand  the  use  of  inhalations  of  chloroform  during 
the  attack  and  morphine  and  chloral  between. 

Prophylaxis.  Successful  stamping  out  of  the  disease  in  man  can 
only  be  accomplished  by  stamping  it  out  in  animals. 

Up  to  1917  the  U.  S.  Department  of  Agriculture  had  not  succeeded  in 
finding  an  efficient  and  practical  disinfectant  for  hides.  (Brown  & 
Simpson.) 

Certainly  more  care  should  be  given  to  disinfection  of  tools,  utensils 
and  vats  in  tanneries.  Instructions  should  be  given  to  the  handlers  of 
hides. 

Infected  animals  should  be  killed  and  remembering  that  the  spores 
are  peculiarly  resistant  and  that  they  are  aerobic  it  is  important  to 
disturb  the  carcasses  as  little  as  possible  and  to  bury  them  deep. 

This  same  resistance  of  the  spores  and  the  fact  that  they  are  ex- 
creted in  urine  and  feces  make  it  difficult  to  stamp  the  disease  out  of 
the  fields  in  which  the  infected  animals  have  been  pastured. 

It  must  be  remembered,  too,  that  these  fields  are  a  menace  to  healthy 
animals. 

SUMMARY 

Treatment  of  malignant  pustule. 

Complete  excision,  well  out  into  sound  tissue. 

Cauterize  this  open  wound  with  liquified  phenol  (liquified  carbolic 
acid)  or  with 

Actual  cautery. 

Carbolic  acid  either  liquified  or  m.  x  to  m.  xv  (0.60-1  c.c.)  of  3  per 
cent,  watery  solution  has  been  injected  all  about  the  excised  area. 

Another  method — Injections  of  phenol  as  above  about  site  of  infec- 
tion.   Poultice  to  the  infected  area  (Bloodgood  and  McGlannan). 
Wound  is  dressed  with  wet  dressing. 
Dudley's  method.    (See  text.)    - 

Specific  treatment. 
Serum  30  to  80  c.c.  daily  under  the  skin  or  into  vein. 


ANTHRAX  685 

Bellevue  Method: 

40  c.c.  intravenously  every  4  hours 

10  c.c.  every  4  hours  into  tissue  about  pustules  given  in  multiple 
punctures  of  one  to  one-half  c.c. 

Serum  from  Department  of  Agriculture. 
When  constitutional  symptoms  are  manifest. 

Rest  in  bed. 

Room. 
Cool,  light,  well  ventilated. 

Bed. 

Hospital  type. 


(See  Typhoid  Fever,  Chap.  XIV  or 
Pneumonia,  Chap.  IX.) 

rom  pustules,  secretions  and  excretions  must  be  de- 


Care  of  body. 

Daily  bath. 
Mouth. 
Nose. 
Genitals. 
Bed-sores. 
Discharges 
stroyed  by  fire  or  disinfected.    (See  Typhoid  Fever,  Chap.  XIV.) 

Diet. 
(See  Chap.  II.) 

Circulation. 

Digitalis. 

Strophanthin. 

Caffeine. 

Camphor. 

Strychnine. 

(See  text,  or  Pneumonia,  Chap.  IX.) 

Headache. 
Ice-bag. 

Restlessness  and  sleeplessness. 

Codeine  phosphate,  gr.  1/8-gr.  1/4  (0.008-0.015  Gm.). 
Morphine  sulphate,  gr.  1/8-gr.  1/4  (0.008-0.015  Gm.). 
Chloral,  gr.  x-gr.  xv  (0.60-1  Gm.). 

Vomiting. 

Stop  food. 

Cracked  ice. 

Mustard  paste  to  epigastrium. 

Bismuth  subnitrate,  gr.  xv  (1  Gm.). 

Sodii  bicarbonate,  gr.  x  (0.60  Gm.). 

Cerium  oxalate,  gr.  v  (0.30  Gm.). 


686  TREATMENT  OF  ACUTE  INFECTIOUS  DISEASES 

Diarrhea.    «r 

Bismuth  subnitrate,  gr.  xxx-5i  (2-4  Gin.)  every  two  hours. 
Opium,  gr.  1/4  (0.015  Gm.)  every  two  hours. 
Starch  enema  with  tincture  of  opium  m.  x-m.  xv  (0.60-1  c.c.). 

Delirium. 
Restraint. 

Morphine  sulphate,  gr.  1/8-gr.  1/4  (0.008-0.015  Gm.). 

Chloral,  gr.  xv  (1  Gm.). 

Hyoscine  hydrobromide,  gr.   1/200-1/150  (0.0003-0.00045  Gm.), 

Prophylaxis. 

Kill  infected  animals  and  bury  their  bodies  deep. 
Avoid  use  of  infected  fields. 


CHAPTER  XXXVI 

GLANDERS  OR  FARCY 

THIS  disease  is  peculiarly  common  among  horses  and  the  horse 
kind,  and  is  communicated  by  them  to  man;  so  that  it  is  in  hostlers, 
drivers,  farmers  and  others  in  intimate  contact  with  the  horse,  the 
mule  or  the  ass  that  the  disease  is  found. 

The  causative  agent  is  the  bacillus  mallei,  which  is  found  in  the 
purulent  discharges  and  in  the  secretions  from  the  infected  mucous 
membranes  and  is  inoculated  into  the  air-passages  or  skin  abrasions 
in  man.  There  is  a  difference  of  opinion  as  to  whether  it  may  enter 
through  the  unbroken  skin. 

When  the  infection  is  received  through  the  air-passages  and  the 
lesion  is  internal  it  is  called  Glanders;  when  through  the  skin  and  the 
lesion  is  external  it  is  called  Farcy. 

The  local  effect  of  the  bacillus  is  the  formation  of  nodules  of  an 
inflammatory  character,  which  break  down  and  form  pustules  and 
ulcers,  whose  discharges  carry  the  infection. 

The  disease  may  run  either  an  acute  or  chronic  course;  so  that  we 
have  Acute  or  Chronic  Glanders  and  Acute  or  Chronic  Farcy. 

Treatment.  The  disease  is  a  toxemia  with  local  manifestations 
and  the  treatment  that  which  is  applicable  to  all  infections,  i.  e.,  meas- 
ures aiming  at  the  support  of  the  body  in  its  contention  with  the  dis- 
ease, specific  treatment,  if  there  be  any,  attention  to  the  local  lesion 
and  relief  of  distressing  or  dangerous  symptoms. 

For  the  first,  rest  in  bed,  with  consideration  for  all  that  constitutes 
rest,  good  nursing,  good  room,  quiet  and  mental  rest,  a  sufficiency 
of  diet  and  fresh  air,  preferably  in  the  open,  meet  the  demands.  (See 
Treatment  of  Acute  Febrile  Conditions  and  Diet  in  Fever,  Chaps.  I 
and  II.) 

The  mortality  of  the  disease  is  high,  but,  as  would  be  expected, 
least  in  the  chronic  form  and  when  confined  to  the  surface  of  the  body, 
chronic  farcy. 

Chronic  Farcy.  The  picture  is  that  of  a  pyemia,  in  which  the 
local  lesion  may  precede  or  follow  the  toxemia,  with,  sooner  or  later, 
multiple  abscesses,  ulcers  and  fistulae  slow  in  progress  and  perhaps 
with  improvement  followed  by  relapse,  and  death  from  emaciation, 


688  TREATMENT  OF  ACUTE  INFECTIOUS  DISEASES 

asthenia  and- overwhelming  by  poisons;  or  at  any  time  acute  glanders 
intervenes  and  hastens  the  fatal  issue. 

Besides  the  supportive  treatment  specified,  above  one  turns  to  the 
use  of  those  substances  that  in  a  sense  may  be  termed  specific,  as  con- 
tributing to  Nature's  own  efforts  and  in  the  same  terms. 

Unfortunately,  the  results  are  but  little  encouraging,  and  yet  any 
assistance  in  so  dread  an  infection  is  welcome.  Of  such  agents  one 
may  mention  mallein. 

Mallein  is  a  toxin  obtained  from  the  bacillus  mallei  much  as  tu- 
berculin from  the  tubercle  bacillus  and  has  many  parallelisms  with 
the  latter. 

Its  particular  usage  is  as  a  test  for  the  presence  of  the  infection, 
used  like  tuberculin  for  a  kindred  purpose  and  provoking  like  the 
latter  in  a  true  case  a  febrile  response  and  a  local  reaction. 

Like  tuberculin,  too,  it  has  been  suggested  as  a  curative  agent,  pro- 
voking in  graduated  doses  increasing  response  in  the  tissues  in  terms 
of  immune  bodies.  Definite  rules  of  dosage  cannot  be  laid  down,  but 
advice  should  be  sought  from  State  or  Municipal  Laboratories  preparing 
the  same  and  acquainted  with  the  reaction  obtained  in  animals.  Few 
have  used  it,  and  their  praise  is  qualified. 

Vaccines.  More  hopefully  one  turns  to  the  use  of  vaccines  and 
though  the  reports  of  successful  cases  are  scanty,  nevertheless  some 
have  been  noted  by  competent  observers. 

Park  (Forchheimer's  Therapeutics  of  Internal  Diseases)  advises 
20,000,000  as  a  beginning  dose  and  gradual  increase  up  to  200,000,000 
or  more  at  four  or  five  day  intervals.  Dosage  is  governed  by  reaction 
as  in  use  of  other  vaccines;  i.  e.,  by  fever,  local  redness  about  site  of 
injection  or  lighting  up  of  local  lesions. 

A  moral  obligation  to  familiarize  himself  with  the  theory  and  prac- 
tice of  vaccine  therapy  rests  on  the  man  who  uses  an  agent,  which 
used  carelessly  is  potent  to  convert  a  local  process  into  a  hopeless 
general  one.  (For  words  of  warning,  see  Theobald  Smith,  Jour.  Am. 
Med.  Association,  May  24,  1913.) 

Serum  reactions,  used  as  diagnostic  tests,  such  as  the  agglutina- 
tion test  and  the  complement  fixation  test,  bespeak  the  presence  of 
immune  bodies,  which  together  with  the  results  in  establishing  immu- 
nity in  animals  by  vaccines  encourage  the  use  of  serum  of  immunized 
animals  as  a  curative  agent  but  unhappily  the  hope  elicited  has  not 
been  sustained. 

Treatment  of  the  Local  Lesions.  The  word  of  warning  not  to 
convert  a  local  lesion  into  a  generalized  infection  has  been  well  given, 
for  too  vigorous  curettage  or  rough  handling  may  break  down  or  thin 


GLANDERS  OR  FARCY  689 

the  walls  of  abscess  or  ulcer,  nature's  barriers,  to  the  defeat  of  her  in- 
tent to  localize  the  infection  by  these  means. 

Abscesses  as  in  other  conditions  should  be  incised  and  evacuated, 
thoroughly  irrigated  and  a  strong  antiseptic  applied,  but  not  roughly 
rubbed  about. 

Liquified  phenol  (carbolic)  is  a  suitable  substance  and  this  may 
be  followed  by  alcohol  to  remove  the  excess.  Wet  dressings  of  bi- 
chloride may  be  used  or  iodoform  gauze  or  tincture  of  iodine  and  a 
light  packing  of  gauze  to  keep  the  wound  open. 

Ravenel  in  Osier's  Modern  Medicine  advises  as  a  caustic  a  1  to  10 
solution  of  chloride  of  lime. 

If  the  lesion  is  small  and  well  localized  excision  is  advisable. 

Chronic  Glanders.  Less  hopeful  than  chronic  farcy,  indeed,  al- 
most hopeless  is  this  condition  in  which  the  upper  air-passages  and 
the  lungs  are  involved,  coming  on  in  the  majority  of  cases  as  a  result 
of  the  chronic  farcy. 

The  treatment  is,  of  course,  the  same,  except  that  not  as  much  can 
be  expected  from  the  vaccines  and  still  less  from  the  use  of  mailein. 

The  nose  with  its  ulcerations,  necrosis  of  bones  and  sinus  involve- 
ment calls  for  local  treatment,  irrigations  of  saline  solutions,  boric 
acid  or  in  the  case  of  much  necrotic  tissue  irrigations  with  permanga- 
nate of  potash  solution,  of  a  deep  claret  color  or  applications  of  per- 
oxide of  hydrogen.  Insufflations  of  iodoform  have  been  suggested. 

The  annoying  cough  may  be  alleviated  by  inhalations  of  steam 
or  medicated  with  compound  tincture  of  benzoin,  oil  of  pine,  creosote, 
or  eucalyptus.  A  teaspoonful  or  two  may  be  added  to  the  inhaler  or 
a  perforated  zinc  inhaler  (Robinson's)  may  be  worn  over  nose  and 
mouth  with  some  mixture  as  creosote,  chloroform  and  alcohol  equal 
parts,  10  to  15  drops  on  the  sponge  of  the  inhaler.  Later  codeine  sul- 
phate or  phosphate  in  doses  of  gr.  1/8  to  gr.  1/2  (0.008-0.030  Gm.) 
at  two  or  three  hour  intervals  may  be  demanded  and  still  later  and 
especially  with  the  distressing  dyspnoea  morphine  sulphate  gr.  1/12  to 
gr.  1/8  (0.005-0.008  Gm.)  at  four-hour  intervals. 

Acute  Farcy.  Here  both  local  and  general  symptoms  are  so  severe 
that  life  is  despaired  of.  The  picture  is  one  of  acute  septic  poisoning, 
and  intense  local  infection,  erysipelatous  or  forming  ulcers,  like  gan- 
grene and  widespread  pustular  eruption. 

Acute  glanders  presents  the  same  picture  as  acute  farcy  with  the 
additional  distress  attendant  upon  involvement  of  the  air-passages. 

Beside  the  supportive  treatment  and  relief  of  symptoms,  nothing 
can  be  added;  for  vaccines  here  can  do  no  good. 

Circulatory  and  respiratory  needs  are  met  by  the  use  of  caffeine, 


690  TREATMENT  OF  ACUTE  INFECTIOUS  DISEASES 

camphor,  atropine,  digitalis  or  strophanthm  as  in  other  infections, 
but  are  used  rather  with  a  feeling  that  an  effort  to  do  something  is 
better  than  laissez  aller;  though  from  the  patient's  standpoint  that 
is  doubtful. 

Doctor  and  nurse  should  remember  that  the  discharges  of  the 
patient  are  infectious  and  take  precautions  accordingly,  by  burning 
all  discharges  and  thoroughly  sterilizing  by  heat  or  strong  solutions 
of  carbolic  acid  clothes  and  linen  contaminated  with  them;  by  steril- 
izing the  dishes  and  implements  used  by  the  patient.  (See  Typhoid 
Fever,  Chap.  XIV.)  Gloves  should  be  used  in  doing  dressings  and 
handling  discharges. 

Isolation.  Acute  cases  should  be  carefully  isolated  and  every 
warning  given  of  the  danger  of  too  close  contact  even  in  the  chronic 
cases. 

Prophylaxis.  As  the  disease  is  always  conveyed  by  the  horse, 
the  appreciation  of  the  disease  in  this  animal  is  of  first  importance 
and  a  skillful  veterinarian  is  often  necessary  to  detect  the  latent  cases. 

Barnett  Cohen  1  advises  as  an  efficient  disinfectant  of  horse  troughs 
the  use  of  hypochlorite  of  Calcium  (i.  e.,  Chloride  of  Lime). 

He  maintains  that  two  parts  of  available  chlorine  in  a  million  in  the 
trough  over  night  will  disinfect  even  in  the  presence  of  much  organic 
matter. 

Infected  animals  should  be  killed  and  the  stables  carefully  disin- 
fected and  the  other  horses  tested  from  time  to  time  to  detect  further 
infection. 

Individuals  handling  horses  known  to  be  infected  should  use  gloves 
and  if  inoculation  is  known  to  have  occurred  excision  of  the  site  is 
advised. 

SUMMARY 

Isolation. 
Must  be  carefully  observed. 

Doctors  and  nurses. 
Should  wear  gloves. 
Avoid  spray  of  cough. 

Destroy  all  secretions  by  burning  or  disinfecting. 
Disinfect  all  articles  used  about  the  patient. 
(See  Typhoid  Fever,  Chap.  XIV.) 

1  Dissolve  0.3  Gm.  of  Chloride  of  Lime  in  some  distilled  water.  Then  filter  and 
titrate  this  stock  solution  before  using  each  time  with  standard  sodium  thiosul- 
phate  N/10  to  determine  the  available  chlorine. 


GLANDERS  OR  FARCY  691 

Chronic  farcy. 
Specific  treatment. 

Mallein.    (See  text.) 
Vaccines. 

Begin    with    20,000,000    and    increase    up    to    150,000,000    or 
200,000,000. 

Give  every  four  or  five  days. 

Dosage  and  frequency  governed  by  reaction. 
Treatment  of  local  lesions. 

(Read  text.) 

Incise  and  evacuate. 
Abscess. 

Irrigate. 

Apply  liquified  phenol  (carbolic  acid). 

Apply  alcohol  to  remove  excess  of  phenol. 

Pack  wound  with  wet  dressing  of  bichloride,  or  iodoform  gauze. 

Excise,  small,  well  localized  lesions. 

Chronic  glanders. 
Specific  treatment,  as  above. 

Care  of  nose. 
Irrigation  with  saline,  0.6  per  cent.  (3i  to  Oi,  4  Gm.  to  500  c.c.)  or  2 

per  cent,  or  4  per  cent,  boric  acid  solution. 
If  much  necrosis 
Irrigate  with  permanganate  of  potash;  make  solution  of  rich  claret 

color  (1:5,000). 
Apply  peroxide  of  hydrogen. 
Iodoform,  insufflated  has  been  recommended. 

Cough. 

Inhalations  of  steam,  medicated  with  one  of  the  following 
Compound  tincture  of  benzoin. 


Oil  of  pine. 

Creosote. 

Oil  of  Eucalyptus. 

A  good  formula  is 


3i  or  ii  (4-8  c.c.)  on  the 
water  of  an  inhaler. 


Alcohol, 

Chloroform,  I  equal  parts. 

Creosote, 

S.  gtt.  v-x  on  sponge  of  a  Robinson's  inhaler  (perforated  zinc 

inhaler  for  nose  and  mouth) . 
Codeine  sulphate  or  phosphate,  gr.  1/8  to  gr.  1/2  (0.008-0.030  Gm.) 

every  two  or  three  hours. 

Morphine  sulphate,  gr.  1/12  to  gr.  1/8  (0.005-0.008  Gm.)  every  four 
hours. 


692  TREATMENT  OF  ACUTE  INFECTIOUS  DISEASES 

Acute  glanders  and 
Acute  farcy 

Relief  of  symptoms,  as  above. 
Circulatory  stimulants. 

Digitalis. 

Strophanthin. 

Caffeine. 

Camphor. 

(See  Pneumonia,  Chap.  IX.) 
Respiratory  stimulants. 

Caffeine. 

Atropine. 

Strychnine. 

Prophylaxis. 

Killing  of  infected  horses. 
Disinfecting  stables. 

Testing  all  animals  in  contact  with  sick  horses. 
Wearing  gloves  in  handling  sick  horses. 
Excise  site  of  any  inoculation. 
Disinfection  of  horse  troughs. 
(See  text.) 


CHAPTER  XXXVII 

FOOT  AND  MOUTH  DISEASE 

(APHTHAE    EPIZOOTICAE)  ' 

THIS  is  essentially  a  disease  of  animals,  but  may  include  man  among 
its  victims.  It  is  extremely  infectious. 

Among  animals  cattle  are  the  most  susceptible;  hogs,  sheep  and 
goats  next;  horses,  cats  and  dogs  occasionally;  certain  fowl  rarely. 
Commonly  severe  among  animals,  it  is  relatively  mild  in  man,  though 
there  are  unfortunately  exceptions  to  this  rule. 

The  cause  is  as  yet  unknown,  no  organism  proven  definitely  re- 
sponsible for  the  disease  having  been  isolated. 

The  virus  has  been  shown  to  pass  through  a  Berkfeld  filter;  hence, 
is  to  be  classed  as  ultramicroscopic. 

It  occurs  more  frequently  in  Summer  than  in  Winter. 

The  incubation  period  is  put  in  Osier's  Modern  Medicine  from  two 
to  ten  days.  It  begins  in  man  with  a  fever  and  other  signs  of  toxemia. 
There  may  also  be  a  gastro-intestinal  catarrh,  especially  in  children. 
The  mucous  membrane  of  the  mouth  is  swollen,  reddened  and  glazed. 
The  palpebral  conjunctive  and  mucous  membrane  of  the  genitals  are 
also  involved  and  in  two  or  three  days  there  appears  the  characteristic 
vesiculation  in  the  mouth  and  between  the  fingers  and  toes  and  fre- 
quently on  the  dorsal  surface  of  the  hands  and  feet  that  gives  the  name  to 
the  disease.  These  vesicles  contain  clear  serum,  which  later  becomes 
cloudy  and  is  extremely  infectious.  They  heal  without  a  scar.  Saliva- 
tion accompanies  the  vesiculation  in  the  mouth.  Immunity  is  said  to 
be  very  short  lived.  Recurrences  have  been  noted  in  10  to  12  days. 

Clough,  whose  article  on  this  condition  in  the  Johns  Hopkins  Bulle- 
tin of  October,  1915,  I  especially  recommend,  epitomizes  the  disease  as 
follows: — "A  mild  febrile  infectious  disease,  characterized  by  the 
appearance  of  an  erythema  and  a  superficial  vesicular  eruption  over  the 
mucous  membrane  of  the  mouth  and  on  the  skin  of  the  hands  and  feet; 
by  salivation,  by  swelling,  burning  and  paraesthesias  of  the  affected 
parts,  with  subsequent  desquamation;  and  by  healing  of  the  ulcers 
without  scar  formation." 

With  the  appearance  of  the  eruption  the  temperature  declines. 

Treatment.     There  is  no  specific  remedy;  so  the  treatment  re- 


694  TREATMENT  OF  ACUTE  INFECTIOUS  DISEASES 

solves  itself  into  efforts  at  relieving  the  effects  of   the  toxemia  and 
the  ulcerations  in  the  mouth  and  on  the  skin. 

The  same  principles  are  applicable  in  this  as  in  other*  infectious 


Rest  in  bed  with  the  choice  of  a  comfortable  narrow  bed  and  firm 
mattress  and  a  room  capable  of  thorough  ventilation  and  accessible  to 
the  sun. 

Isolation.  The  disease  is  contagious,  so  only  those  who  minister  to 
the  needs  of  the  patient  should  be  admitted. 

Physicians  and  nurses  should  use  gloves  in  handling  the  patient, 
treating  the  ulcers  and  handling  the  secretions.  These  latter  should 
be  burned. 

Articles  coming  in  contact  with  the  patient  such  as  thermometers, 
dishes,  bed-pans,  urinals,  bed  clothing,  should  be  handled  as  in  other 
infectious  diseases.  (See  Typhoid  Fever,  Chap.  XIV.) 

Diet.  Feeding  is  difficult  on  account  of  the  condition  of  the  mouth; 
the  ulcerations  affecting  it  in  particular  and  extending  into  the  pharynx, 
oesophagus,  the  larynx  and  trachea.  This,  of  course,  makes  chewing 
and  swallowing  very  difficult. 

The  food  should  be  liquid  or  of  nearly  fluid  consistency  and  con- 
centrated; milk,  and  milk  fortified  with  milk  sugar  and  cream,  say 
an  ounce  of  each  to  each  glass  of  milk  and  soups  made  of  milk  and 
farinaceous  flours  or  cereals,  cereal  jellies  and  eggs,  may  be  taken  as 
the  basis  of  such  a  dietary. 

It  may  be  necessary  to  use  the  stomach  tube  or  nasal  tube  or  have 
recourse  to  rectal  feeding,  especially  in  children  or  illy  nourished  in- 
dividuals. Water  should  be  given  freely.  It  must  be  determined 
that  the  milk  does  not  come  from  infected  sources  and  if  there  is  an 
element  of  doubt  it  should  be  boiled. 

Fever  is  rarely  high  or  long  continued.  If  any  antipyretic  measure 
is  used  at  all,  hydrotherapy  in  the  shape  of  cold  sponges  offers  the  only 
legitimate  one. 

Daily  sponge  baths  for  cleanliness  should  always  be  given. 

Circulation.  Evidences  of  faltering  circulation  should  be  met 
by  the  same  measures  used  in  other  infections.  (See  Pneumonia,  Chap. 
IX.) 

Care  of  Mouth.  This  is  of  the  most  vital  importance  for  here 
a  fatal  sepsis  may  begin  or  pain  and  discomfort  sacrifice  nutrition  to 
the  danger  point. 

The  best  means  of  keeping  the  mouth  in  condition  is  by  abundant 
irrigations  of  warm  saline  solution  (see  Scarlet  Fever,  Chap.  XVII), 
or  one  may  use  boric  acid  2  per  cent,  or  quarter  strength  DobelTs 


FOOT  AND  MOUTH  DISEASE  695 

solution.  This  should  be  done  after  each  feeding  and  it  were  well  to 
give  a  small  irrigation  before  a  feeding  on  account  of  the  abundant 
secretions  from  the  salivary  glands  gathering  in  the  mouth  and  on 
account  of  the  detritus  from  the  ulcers.  This  is  especially  important 
in  the  morning. 

Food  must  be  removed  from  the  dead  spaces  between  the  gums 
and  teeth  by  swabs  on  wooden  toothpicks  or  other  applicators;  one  of 
the  above  solutions  is  used  to  moisten  the  sponges. 

The  best  treatment  for  the  ulcers  is  to  touch  each  with  silver  nitrate 
stick  or  with  small  swabs  wetted  with  25  per  cent,  to  50  per  cent,  silver 
nitrate. 

If  the  mouth  is  very  foul  one  may  irrigate  with  permanganate  of 
potash  solution  made  to  a  deep  claret  color  (1:  5000). 

Chlorate  of  potash  solutions  may  be  used  as  mouth  wash  or  gargle, 
1  per  cent,  to  2  per  cent.,  or  if  painful,  of  lesser  strength.  The  nose, 
too,  must  receive  similar  attention. 

In  severe  cases  the  palpebral  conjunctiva  may  be  involved. 

Eye  washes  of  boric  acid  solutions  2  per  cent,  to  4  per  cent,  should  be 
used  and  if  there  is  much  swelling  and  pain,  cold  compresses,  using  the 
same  solutions,  may  be  applied. 

Vesicles  and  Ulcers  of  Skin.  These  are  usually  confined  to  fingers 
and  toes  and  region  of  mouth  and  nose,  but  in  some  cases  may  be  more 
generally  distributed. 

The  ulcers  are  usually  shallow.  Drying  powders,  like  sterile  tal- 
cum powder,  is  best  used  on  vesicles  and  ulcers  or  such  a  powder  as 
aristol  on  the  latter. 

If  there  is  annoying  itching  those  measures  recommended  for  the  same 
condition  in  Varicella,  Measles  and  Small  Pox  may  be  applied.  (See 
Chaps.  XXI,  XIX,  XXVII.) 

It  must  be  remembered  that  the  contents  of  these  blebs  are  con- 
tagious. 

Gastro-enteric  Symptoms.  These  at  times  may  be  severe  with 
much  colicky  pain  and  diarrhea. 

A  thorough  cleaning  out  with  castor  oil  followed  by  small  doses 
of  the  oil  m.  x  (0.65  c.c.)  every  two  hours  or  by  bismuth  subnitrate  3ss. 
(2  Gm.)  every  two  hours  with  local  applications  of  heat  to  the  abdomen 
may  relieve  the  distress,  or  small  doses  of  opium  may  be  necessary,  m.  i 
(0.06  c.c.)  of  deodorized  tincture,  every  two  hours. 

The  duration  is  about  two  weeks,  though  it  may  last  somewhat 
longer. 

Death  is  not  a  common  issue  except  among  sickly  children. 

Prophylaxis.     The  disease  is  transmissible  through  the  contents 


696  TREATMENT  OF  ACUTE  INFECTIOUS  DISEASES 

of  the  vesicles  of  diseased  animals  and  through  the  saliva,  also  through 
the  milk  or  the  products  of  milk,  e.  g.,  butter,  cheese  and  cream  of 
diseased  animals;  hence,  workers  about  animals  and  children  drinking 
the  milk  are  peculiarly  prone  to  contract  the  disease,  and,  as  might  be 
expected,  the  mouth  is  first  affected  in  those  drinking  the  milk.  Cattle 
affected  should  be  killed  and  a  thorough  disinfection  of  the  stable,  etc., 
follow. 

Suspected  milk  should  not  be  drunk  or  should  be  sterilized  and  all 
suspected  meat  destroyed. 

SUMMARY 

Treatment. 

Local,  of  ulcerations  in  mouth  and  skin. 
General,  to  relieve  effects  of  toxemia. 

Rest. 

Bed,  hospital  type  preferred. 
Room,  well  ventilated  and  lighted. 
Quiet. 
Isolation. 

Physicians  and  nurses  wear  gloves  in  handling  patient  and  secre- 
tions. 

Treatment  of  objects  in  contact  with  patient  and  of  secretions.    (See 
Typhoid  Fever,  Chap.  XIV.) 

Diet. 

Liquid  or  of  fluid  consistency. 

Milk,  whixjh  may  be  fortified  with  sugar  or  cream. 

Soups  of  milk,  cereals,  farinaceous  flours. 

Cereal  jellies. 

Eggs. 

Avoid  milk  from  infected  sources,  or  if  in  doubt  boil  it. 

May  have  to  use  stomach  or  nasal  tube  or  have  recourse  to  rectal 

feeding. 
Water,  give  freely. 

Bowels. 

Initial  dose  of  castor  oil  5ss.  to  i  (15-30  c.c.)  preferred  if  there  is 
diarrhea,  or  a  salt  gss.-i  (15-30  Gm.). 

Fever. 

Rarely  requires  interference,  or  at  the  most  cool  sponges. 

Circulation. 

(See  measures  used  in  Pneumonia,  Chap.  XIV.) 


FOOT  AND  MOUTH  DISEASE  697 

Care  of  mouth. 
Abundant  irrigations  of  warm  saline  (see  Scarlet  Fever,  Chap.  XVII) 

or  of  2  per  cent,  boric  acid  or  quarter  strength  Dobell's  solution. 
Well  to  precede  feeding  by  a  lesser  irrigation;  especially  in  the  morn- 
ing. 
Swabs  or  toothpicks  wetted  with  solutions  mentioned  to  free  dead 

spaces  between  cheeks  and  teeth  and  interstices  of  teeth  from 

food. 
Ulcers  of  mouth. 

Touch  with  silver  nitrate  stick  or  25  per  cent,  to  50  per  cent,  silver 
nitrate  solution. 

Chlorate  of  potash  solution,  1  per  cent,  to  2  per  cent.,  as  a  mouth 

wash. 
If  mouth  is  foul, 

Permanganate  solution  of  a  rich  claret  color  1 :5000. 

Nose. 

Cleansed  with  saline,  boric  acid  or  Dobell's  solution. 

Eyes. 

Boric  acid  solutions  2  per  cent,  to  4  per  cent,  as  eye-washes. 
Cold  compresses  of  boric  acid  solutions,  2  per  cent,  to  4  per  cent. 

Vesicles  and  ulcers  of  the  skin. 
Drying  powders  or  aristol. 

(For  itching  see  Small  Pox  and  Varicella,  Measles.  Chaps.  XXVII, 
XXI,  XIX.) 

Gastro-intestinal  symptoms. 
Colicky  pains. 
Hot  fomentations. 

Diarrhea. 

Preliminary  dose  of 

Castor  oil  5ss.-i  (15-30  c.c.). 

Follow  by  castor  oil  in  small  doses,  m.  x  (0.65  c.c.),  every  two  hours. 

Bismuth  subnitrate, 

gr.  xxx  (2  Gm.),  every  two  hours. 
If  much  pain. 

Opium,  deodorized  tincture,  m.  i  (0.06  c.c.)  every  two  hours. 

Prophylaxis. 

(See  text.) 


CHAPTER  XXXVIII 

PSITTACOSIS 

THIS  is  a  disease  incurred  from  parrots,  resembling  an  atypical, 
pneumonia;  atypical  in  its  physical  signs  and  in  its  course,  and  Osier 
says  characterized  by  an  onset  like  typhoid  fever. 

An  organism  belonging  to  the  hog-cholera  group  was  isolated  by 
Nocard  and  shown  by  him  to  precede  the  disease  in  other  parrots  and 
other  animals. 

The  incubation  has  been  set  as  short  as  a  week  and  as  long  as  three 
weeks  or  more. 

The  diagnosis  is  made  when  a  case  and  especially  several  cases  occur 
in  a  family  where  there  are  sick  parrots. 

It  is  to  be  treated  like  any  pneumonia,  especially  bronchopneu- 
monia,  and  the  same  considerations  of  choice  of  room,  bed,  diet,  air 
and  attention  to  the  circulation  with  relief  of  annoying  symptoms 
obtain  in  the  one  as  in  the  other.  (See  Pneumonia,  Chap.  IX.) 

The  disease  in  cases  that  get  well  runs  from  two  to  three  weeks.  The 
disease  is  a  severe  one  as  the  mortality  of  35  per  cent,  to  40  per  cent, 
indicates. 

Prophylaxis.  Caution  in  handling  sick  parrots  and  disinfection  of 
cages  and  utensils  in  contact  with  the  bird. 

Isolation  of  patient,  destruction  of  secretions,  especially  bronchial 
secretions. 

SUMMARY 
Treat  like  a  Pneumonia.    (See  Chap.  IX.) 


CHAPTER  XXXIX 

RABIES 

(HYDROPHOBIA) 

THIS  disease,  relatively  rare  in  the  experience  of  the  individual 
practitioner,  when  once  encountered,  leaves  on  his  mind  a  more  indeli- 
ble stamp  of  horror  than  any  other  he  will  meet. 

It  is  conveyed  to  man  in  the  vast  majority  of  instances  through 
the  bite  of  the  dog.  It  is  true  that  all  mammals  are  susceptible  to  it 
and  that  here  and  there  on  the  earth's  surface  other  animals  than  the 
dog  may  play  a  leading  rdle  in  its  transmission,  as  the  wolf  in  Russia. 
In  this  country  as  high  as  4  per  cent,  has  been  attributed  to  the  cat, 
while  skunks  and  horses  are  to  be  remembered  as  sources  of  rabies. 

The  virus  is  transmitted  by  the  saliva  of  the  rabid  animal  and,  like 
tetanus  toxin,  has  an  especial  affinity  for  the  nervous  system,  entering 
the  nerve  endings  at  the  site  of  the  wound,  travelling  by  the  nerve 
trunks  to  the  spinal  cord  and  by  the  cord  to  the  medulla  and  brain, 
unless  the  wound  be  on  the  face,  whence  the  route  to  the  brain  struc- 
tures is  more  direct.  In  respect  to  its  route  and  in  respect  to  the  vari- 
ability of  its  incubation  period  which  depends  on  the  length  of  the  route 
travelled  to  the  central  nervous  system,  it  finds  in  tetanus  toxin  a  close 
analogue. 

The  source  of  the  virus  is  probably  but  not  certainly  known.  Its 
incubation  period  and  its  multiplication  in  the  animal  body  demands 
a  living  organism  as  its  origin.  The  so-called  Negri  bodies,  charac- 
teristically present  in  the  nerve  centres,  and  now  recognized  as  the 
pathological  criterion  of  the  disease,  are  probably  the  infecting  or- 
ganisms. Competent  authorities  are  inclined  to  place  these  bodies 
among  the  protozoa  and,  indeed,  to  fix  them  more  definitely  in  sub- 
orders and  families  of  this  kingdom. 

In  the  nervous  system  they  are  especially  readily  found  in  the  cere- 
bral and  cerebellar  cortex,  in  the  hippocampus  major  (in  the  horn  of 
Ammon)  and  in  the  corpus  striatum  (in  98  per  cent,  or  more). 

Less  than  10  per  cent,  of  men  bitten  by  rabid  dogs  develop  hydro- 
phobia and  yet  every  man  developing  the  disease  is  doomed  to  die. 
What  determines  on  the  one  hand  this  relative  immunity  and  on  the 
other  the  fatal  virulency  is  one  of  several  puzzling  problems  this  disease 


700  TREATMENT  OF  ACUTE  INFECTIOUS  DISEASES 

has  offered  to  the  student  of  infections.  ..The  pathological  studies 
of  Paltauf  have  given  reason  to  believe  that  the  immunity  of  the  90 
per  cent,  is  not  due  to  failure  of  infection,  but  to  the  operation  of  an 
unknown  mechanism  of  defense  in  the  central  nervous  system  which 
is  efficient  before  symptoms  arise  or  fails  utterly.  (For  resume  of  these 
studies,  see  Editorial  on  Pathology  of  Rabies  in  the  Journal  of  the 
American  Medical  Association,  May  14,  1910.) 

Incubation.  As  in  tetanus  the  length  of  this  period  depends  on 
the  time  taken  to  pass  by  the  nerve  from  periphery  to  centre;  hence, 
the  length  of  the  nerve  trunk,  or  in  other  words,  the  site  of  the  wound. 
For  this  reason  the  incubation  period  after  bites  on  the  face  or  head  is 
much  shorter  than  bites  on  the  extremities.  Moreover  some  other  factor 
operates  to  delay  the  incubation  in  some  cases,  lengthening  out  to 
months  and  even  a  year  or  more. 

It  may  be  as  short  as  fourteen  days. 

The  average  is  set  by  some  authors  as  forty  days,  but  eight  to  twelve 
weeks  is  common  enough. 

When  a  man  is  bitten  by  a  dog  suspected  of  rabies  our  procedures 
are: 

1.  Immediate  treatment  of  the  wound. 

2.  Confirmation  of  the  suspicion. 

3.  Preventive,  antirabic  or  Pasteur  treatment. 

Treatment  of  the  Wound.  When  there  is  the  least  suspicion 
of  the  dog  the  wound  should  be  treated  drastically  by  cauterization. 

Lacerated  bites  are  worse  than  others;  bites  on  exposed  surfaces 
more  dangerous  than  those  through  clothes;  for  in  these  much  saliva 
may  be  rubbed  off  the  teeth;  bites  on  the  face  or  head  are  more  to  be 
feared  than  those  on  the  extremity,  especially,  because  of  the  short- 
ness of  the  incubation  period,  and  the  virulency  varies  in  different 
animals;  wolves  are  the  worst  (infection  as  high  as  60  per  cent.),  and 
cat's  bites  are  said  to  be  more  virulent  than  those  of  dogs.  No  con- 
siderations, however,  of  "more"  or  "less"  dangerous  should  modify 
the  thoroughness  of  the  local  treatment. 

The  wound  should  be  thoroughly  laid  open,  especially  punctured 
wounds,  bleeding  encouraged,  or  when  seen  immediately  after  the 
bite,  may  be  sucked  (a  procedure  not  absolutely  free  from  danger, 
but  still  a  very  slight  risk) . 

The  wound  should  be  thoroughly  washed  and  liberally  bathed  with 
an  antiseptic  like  bichloride  1  to  1,000,  then  wiped  dry  and  cauterized. 

There  is  a  consensus  of  opinion  that  fuming  nitric  acid  is  the  best 
caustic  for  this  purpose.  It  may  be  applied  on  a  glass  rod  or  other 
suitable  applicator  and  should  search  all  parts  of  the  wound  thor- 


RABIES  701 

oughly.  When  the  pain  of  the  procedure,  as  in  children,  might  lead 
one  to  sacrifice  thoroughness,  it  is  well  to  use  a  general  anaesthetic 
or  a  local,  as  cocaine.  After  the  application  of  the  acid  the  wound  may 
be  washed  with  a  physiological  salt  solution  or  a  saturated  solution 
of  bicarbonate  of  soda  and  with  alcohol.  Park  says  that  wounds  so 
treated  by  the  acid,  contrary  to  general  opinion,  heal  well  and  with 
little  scarring.  There  is  experimental  evidence  to  show  that  this  caustic 
lessens  the  incidence  of  rabies  after  infection. 

Other  caustics,  inferior,  but  still  of  value,  when  nitric  acid  cannot 
be  had  are  phenol  (carbolic  acid),  and  tincture  of  iodine. 

Phenol  should  be  used  full  strength  (95  per  cent.)  and  as  thoroughly 
as  the  nitric  acid. 

After  the  cauterization,  the  excess  should  be  removed  by  swabbing 
with  absolute  alcohol.  Bloodgood  and  McGlannan  (Musser  and 
Kelly,  Practical  Treatment)  use  first  the  carbolic,  follow  it  by  the  fuming 
nitric  acid  and  then  wash  the  wound  with  a  saturated  solution  of  bi- 
carbonate of  soda. 

Of  the  two  other  caustics  mentioned  my  preference  would  be  for  the 
tincture  of  iodine. 

Gumming  (Journal  American  Medical  Association,  May  18,  1912) 
prefers  5  per  cent,  formaldehyde  applied  to  the  wound  twelve  hours  to 
either  phenol  or  nitric  acid.  The  actual  cautery  has  also  been  used. 
Nitrate  of  silver  is  useless. 

After  the  cauterization  a  dry  dressing  is  applied.  If  the  wound 
suppurates  it  is  to  be  treated  as  from  any  other  cause,  kept  open  and 
dressed. 

The  sooner  the  wound  is  treated  the  more  efficient  will  be  the  pro- 
cedure; this  does  not  mean,  however,  that  the  wound  should  not  be  so 
treated,  if  seen  later.  In  fact,  it  should  be  the  routine,  scabs  on  older 
bites  should  be  removed,  the  wound  cleansed  and  cauterized  as  above. 
Rosenau,  calling  attention  to  the  length  of  time  the  virus  may  remain 
latent  in  the  wound,  suggests,  with  reason,  the  excision  of  the  scab  and 
treatment  of  the  wound  as  an  open  one. 

In  fresh/  wounds  on  the  extremity  a  tourniquet  may  be  advisable 
until  the  wound  can  be  cauterized. 

If  the  wound  is  sucked,  the  mouth  should  be  carefully  and  thor- 
oughly rinsed  with  antiseptic  solutions. 

Confirmation  of  the  Diagnosis.  If  the  animal  manifest  the  symp- 
toms of  rabies,  the  head  should  be  sent  to  the  laboratory  for  pathological 
examination  and  the  preventive  treatment  be  begun  at  once,  because 
a  failure  of  pathological  diagnosis  should  not  controvert  a  clinical 
diagnosis  where  the  price  of  an  error  would  be  so  terrible. 


702  TREATMENT  OF  ACUTE  INFECTIOUS  DISEASES 

When  the,animal  has  disappeared  and  cannot  be  found,  an  unwar- 
ranted attack  by  the  beast  should  indicate  the  treatment,  while,  of 
course,  a  provocation  of  an  animal  apparently  of  a  normal  behavior 
weighs  against  the  advisability  of  the  measure. 

Where  any  doubt  exists,  however,  the  patient  should  receive  treat- 
ment. 

When  the  animal  is  secured  and  shows  no  evidences  of  rabies  he 
should  be  confined  for  at  least  three  weeks.  But  if  rabies  has  occurred 
recently  in  the  locality,  the  treatment  should  be  given  in  the  mean- 
time. 

If  no  symptoms  develop  in  this  time  the  danger  may  be  considered 
past  and  the  Pasteur  Treatment  unnecessary  (Rosenau,  Preventive 
Medicine  and  Hygiene). 

Of  course,  if  symptoms  of  rabies  develop  at  any  time  during  this 
period  of  observation  treatment  should  be  begun  at  once. 

When  the  wound  is  on  the  extremity  in  an  adult  the  prolonged  period 
of  incubation  furnishes  enough  time  to  establish  immunity  by  the 
treatment,  but  when  the  wound  is  in  a  child  and  more  especially  on 
the  face  or  upper  extremity  the  shortened  period  of  incubation  makes 
every  day's  loss  during  this  term  of  observation  a  source  of  increasing 
anxiety,  but  if  symptoms  in  the  dog  do  appear,  it  will  be  too  late  to 
establish  immunity. 

Animals  in  the  early  stages  of  rabies  are  prone  to  lick  their  mas- 
ter's hand  or  face  and  while  the  probability  of  infection  by  these  means 
are  not  comparable  to  that  following  a  bite,  the  mere  fact  that  Park 
(Forchheimer,  Therapeusis  of  Internal  Diseases)  can  cite  at  least  eight 
fatal  cases  to  his  knowledge  following  this  mode  of  infection  makes  his 
advice  to  take  the  treatment  almost  an  imperative  command. 

Shooting  of  a  dog  before  symptoms  are  obvious  defeats  the  diag- 
nosis, pathological  as  well  as  clinical. 

Symptoms  of  Rabies  in  the  Dog.  The  earliest  evidences  of  the 
disease  are  perhaps  manifested  in  a  change  of  disposition  of  the  dog;  he 
is  unlike  himself,  secretive,  hiding  himself,  irritable,  uneasy  and  rest- 
less, abstracted,  destructive  of  objects,  apt  to  run  away  from  home  and 
later  bites  without  provocation,  a  striking  symptom  in  a  gentle  dog. 
A  change  in  the  timbre  of  the  voice  is  very  significant.  In  two  to  four 
days  the  furious  delirium  hi  which  the  dog  attacks  man  and  animals 
and  objects,  followed  by  paralysis,  occurs,  or  the  paralytic  stage  ensues 
without  that  of  furious  delirium  (dumb  rabies). 

Unlike  the  human  being  the  rabid  dog  has  no  fear  of  water.  The 
dog  dies  in  a  week  or  less  from  the  first  appearance  of  symptoms. 

Two  popular  beliefs  are  to  be  combated;  first,  that  a  rabid  animal 


RABIES  703 

always  froths  at  the  mouth,  and  second,  that  rabies  is  confined  to  the 
hot  "dog  days"  of  summer. 

Preventive  Treatment.  Had  Pasteur  contributed  nothing  more 
to  human  welfare,  his  work  on  rabies  alone  would  have  raised  for  him 
a  sign  to  all  time  ten-thousand  fold  better  than  a  "monumentum  acre 
perennius." 

The  essence  of  his  discovery  was  that  the  virus  of  rabies,  localizing 
in  the  nervous  system  could,  under  certain  conditions  and  environ- 
ments, be  so  modified  in  its  virulency  as  to  be  used  in  other  animals 
to  provoke  the  mechanism  of  defense  to  the  active  production  of  im- 
mune bodies;  in  other  words,  to  establish  immunity;  and  that,  too, 
with  an  expedition  that  forestalled  the  multiplication  of  the  virus 
already  introduced  to  a  degree  dangerous  to  the  patient. 

Improvements  in  technique  have  been  engrafted  on  his  treatment, 
but  it  fundamentally  remains  the  same  to-day  as  when  he  de- 
vised it. 

Pasteur  first  used  the  virus  attached  to  the  nerve  tissue  of  rabid 
dogs  brought  in  from  the  street  and  to  this  kind  of  virus  has  been  given 
the  designation  of  "street"  virus.  He  soon  found  that  the  virulency 
of  this  "street"  virus  was  variable  and  that  rabbits  injected  with  it 
showed  an  incubation  period  of  fourteen  to  twenty-one  days.  In  his 
effort  to  overcome  this  variability  he  found  that  running  it  through 
rabbits,  that  is,  dog  to  rabbit  and  then  rabbit  to  rabbit,  it  became 
progressively  more  virulent  as  measured  by  the  shortening  incubation 
period  up  to  a  fixed  period  beyond  which  he  could  not  go,  of  six  days. 

This  virus  he  called  "fixed"  virus  and  found  constant  in  its  potency 
and  in  its  effects  for  his  purpose. 

One  other  mysterious  change  was  wrought  in  this  virus  in  the  process 
of  fixing.  It  was  found  to  lose  virulency  in  the  dog  becoming  even 
avirulent  in  man  while  it  was  increasing  in  virulency  in  the  rabbit. 
Adequate  explanations  for  these  facts  are  not  yet  forthcoming  and,  yet, 
on  it  depends  its  efficacy  in  treatment. 

His  next  step  was  to  obtain  this  virus  in  varying  but  definite  de- 
grees of  virulency.  This  was  accomplished  by  taking  the  spinal  cord 
(as  more  easily  manipulated  than  the  brain)  of  a  rabbit  dead  of  the 
effects  of  the  "fixed"  virus  and  drying  it  over  potassium  hydroxide  in  a 
bottle  at  70°  F.  kept  in  the  dark.  Day  by  day  as  the  cord  desiccates 
it  loses  its  virulency  until  the  fourteenth  day  when  it  is  no  longer  capable 
of  inducing  infection.  For  a  brief  resume  of  the  technique  of  preparation 
of  the  virus  used  by  the  New  York  Board  of  Health,  see  Park  in  Forch- 
heimer's  Therapeusis  of  Internal  Diseases. 

Portions  of  the  cords  dried  longest  are  ground  into  an  emulsion 


704  TREATMENT  OF  ACUTE  INFECTIOUS  DISEASES 

in  physiological  salt  solution  and  injected  .under  the  skin  of  the  ab- 
dominal wall.  Each  day  this  injection  is  repeated,  using  portions  of 
cords  dried  a  lesser  period,  i.  e.,  of  increasing  virulency  (for.  the  rabbit) 
until  the  stronger  cords  are  used. 

Slight  modifications  of  the  original  Pasteur  scheme  of  inoculations 
are  adopted  by  different  institutes  and  laboratories. 

The  suitable  scheme  for  the  virus  used  is  furnished  the  practitioner 
by  the  institution  supplying  the  virus,  when  it  is  necessary  for  him 
to  administer  treatment. 

The  duration  of  the  treatment  is  from  fifteen  to  twenty-six  days, 
which  fortunately  is  short  of  the  usual  incubation  period,  in  most  cases, 
although  full  immunity  does  not  obtain  until  four  or  five  weeks  are 
past.  Bites  about  the  head  and  especially  in  children  may,  however, 
be  followed  by  so  short  an  incubation  period  or  the  patient's  treatment 
may  be  begun  so  late  after  the  bite  that  immunization  cannot  be  achieved 
by  the  original  Pasteur  scheme.  Shorter  incubation  periods,  too,  follow 
the  bites  of  wolves  and  cats.  It  becomes  a  great  desideratum,  then,  to 
hasten  the  process  of  immunization. 

It  is  the  custom,  therefore,  in  case  of  bites  about  the  head  to  treat 
the  patient  morning  and  evening  for  the  first  two  days,  or  to  make 
the  treatment  more  intensive  by  using  the  stronger  cords  earlier. 

More  recent  work,  however,  has  given  promise  of  a  quicker  method 
of  immunization  by  the  use,  from  the  first  of  unchanged,  fresh  virus. 
Proescher  of  Pittsburg  has  been  a  pioneer  in  this  work  in  this  country. 
(For  details,  see  Archives  of  Internal  Medicine,  September  15,  1911.) 
He  uses  the  "fixed"  virus  in  the  brains  of  rabbits.  Three  c.c.  of  an 
emulsion  in  physiological  salt  solution  containing  0.01  gram  of  "  virus 
fixe  "  is  injected  subcutaneously  in  the  abdominal  wall  and  0.05  grams 
used  in  the  course  of  the  whole  treatment  of  one  injection  each  day  for 
five  days. 

If  immunity  is  really  established  in  this  time  as  from  his  results 
Proescher  believes  it  to  be,  certainly  a  great  stride  has  been  made 
towards  the  perfection  of  the  procedure  of  immunization. 

When  a  State  or  Municipal  Laboratory  or  Institute  is  at  hand, 
patients  should  be  treated  there  preferably;  but  as  these  are  accessible 
to  the  relatively  few  the 

Treatment  at  a  distance  from  the  laboratory  becomes  of  great 
importance. 

This  is  effected  by  sending  pieces  of  desiccated  cord  with  instruc- 
tions for  the  emulsification  or  the  emulsion  is  sent  in  a  preservative 
of  carbolic  or  glycerin  or  is  supplied  by  manufacturers  in  syringes 
ready  for  use,  as  diphtheria  antitoxin  has  long  been  put  up. 


RABIES  705 

The  U.  S.  Public  Health  and  Marine  Hospital  Service  have  been 
accustomed  to  furnish  virus  to  State  Boards  of  Health  to  be  used  under 
their  direction  and  have  found  the -results  perfectly  satisfactory.  More 
recently  commercial  houses  have  facilitated  the  use  of  rabies  vaccine 
by  despatching  appropriate  doses  with  specific  directions  to  the  family 
physician. 

The  treatment  requires  no  special  confinement,  but  the  patient 
should  avoid  fatigue  or  excesses  of  any  kind.  Very  little  or  any  dis- 
turbance occurs  as  a  result  of  the  treatment  in  the  vast  majority  other 
than  those  that  may  naturally  be  attributed  to  the  concern  of  the  patient 
as  to  the  outcome  of  his  infection,  mild  rashes  or  slight  anaphylactic 
manifestations. 

In  rare  instances  more  serious  results  ensue  in  an  affection  of  the 
nervous  system,  causing  neuralgia,  paVaesthesia  and  even  paralysis, 
paraplegias,  ascending  paralysis  and  death.  The  fatal  issue  is  extremely 
rare.  Whether  this  is  due  to  the  virus  itself  or  is  an  anaphylactic 
phenomenon  is  not  settled. 

They  occur  late  in  or  following  upon  the  treatment.  They  last  a 
few  days  to  several  weeks.  Treatment  is  symptomatic. 

There  are  no  contraindications  to  the  treatment. 

It  is  remarkable,  as  has  been  commented,  that  in  the  100,000  cases 
in  which  this  living  virus  from  the  rabbit  has  been  used,  it  has  induced 
rabies  in  no  instance. 

Just  how  long  the  immunity  so  established  lasts  is  not  determined 
but  probably  for  some  years;  however,  a  patient  bitten  again  by  a  mad 
dog  should  certainly  repeat  the  process  of  immunization  unless  the 
second  bite  follows  close  upon  the  first. 

Results  of  Preventive  Treatment.  It  is  hard  to  confine  one- 
self to  the  bare  statement  of  facts,  when  so  much  that  is  dramatic 
invites  to  an  ebulition  of  enthusiasm.  Granted  that  10  per  cent,  of 
the  bites  from  rabid  dogs  resulted  in  rabies.  All  these  cases  meant 
death,  without  exception. 

What  the  preventive  treatment  has  done  is  best  shown  by  statis- 
tics; 30,000  cases  treated  by  the  Pasteur  Institute  in  Paris  gave  a  mor- 
tality of  0.5  per  cent,  to  1  per  cent. 

Park's  statistics  of  2405  cases  treated  by  the  New  York  Board  of 
Health  virus  showed  a  mortality  of  4  per  cent,  among  those  bitten 
on  the  head  and  3  per  cent,  among  those  bitten  elsewhere:  but  his 
statistics  further  show  that  if  time  for  the  full  development  of  im- 
munity passes,  that  is  two  weeks  beyond  the  full  course  of  treatment, 
the  mortality  sinks  to  0.3  per  cent,  in  the  first  and  0.2  per  cent,  in  the 
latter  class  of  cases. 


706  TREATMENT  OF  ACUTE  INFECTIOUS  DISEASES 

Symptoms  of  Hydrophobia.  They  have  been  divided  into  three 
stages: 

1.  Premonitory   stage,    characterized    by   malaise,    irritability,    de- 
pression, anxiety,   change  in  disposition,  difficulty  in  taking  water, 
hoarseness,  some  nervous  twitchings  or  rigors,  lasts  a  day  or  two,  at 
times  longer. 

2.  Stage  of  excitement.     Great  thirst  and  spasms  of  muscles  of 
deglutition,  the  real  hydrophobia,  intense  hypersesthesia  that  dreads 
even  the  breath  of  bystanders  on  the  skin,  convulsions  and  delusions. 

3.  Paralytic  stage.    Paralysis,  coma  and  death. 

The  paralytic  stage  may  come  early  and  dominate  the  picture. 

Treatment  of  the  Developed  Disease.  I  know  of  no  more  dis- 
tressing duty  that  falls  to  the  lot  of  a  practitioner  of  medicine  than 
this  nor  any  that  has  left  the  indelible  impression  on  my  own  mind 
that  this  sad  experience  has  impressed. 

To  my  mind  it  has  only  one  object,  to  lessen  the  patient's  sufferings 
and  smooth  the  way  to  the  end. 

Another  peculiarity  that  marks  the  disease  as  different  from  others 
is  that  there  is  no  partial  immunity  established;  it  is  all  or  none.  Its 
onset  spells  death  and  the  dubious  rare  report  of  a  recovery  (undoubt- 
edly most  often  a  lyssophobia  or  nervous  symptom  complex  precipitated 
by  fear)  gives  no  warrant  to  exhaust  those  measures  designed  to  pro- 
long life  to  the  provocation  of  renewed  agonies  and  to  add  hours  of 
suffering  without  result. 

The  room  should  be  darkened  and  quiet,  and  all  noise,  talking,  un- 
necessary handling  rigorously  excluded. 

I  have  heard  the  patient  plead  to  avoid  the  draught  from  an  open 
door,  stuff  the  chinks  about  the  window,  stand  further  away  and  turn 
the  head  while  speaking  to  avoid  the  air. 

Only  those  who  can  be  of  help  should  be  present.  What  little  food 
can  be  taken  should  be  concentrated  and  suggest  fluid  as  little  as  possi- 
ble, such  as  ice  cream,  custard,  or  junket.  The  bed  should  be  of  the 
hospital  type  to  facilitate  handling. 

Enemtaa  seem  to  be  the  only  humane  way  to  relieve  the  intense 
thirst. 

In  the  early  stages  of  nervous  irritability  and  hyperaesthesia  large 
doses  of  chloral  and  bromides  by  the  rectum  may  cause  some  sedative 
effect.  The  doses  should  be  liberal  gr.  xxx  (2  Gin.)  of  chloral  and  3i 
(4  Gm.)  of  bromide  or  even  larger  doses  of  both  in  the  adult. 

When  the  convulsive  paroxysms  come  on,  only  chloroform  by  in- 
halation is  of  use,  while  morphine  hypodermatically  may  lessen  their 
frequency  and  the  patient's  suffering  and  horror  in  some  measure. 


RABIES  707 

The  amounts  of  these  drugs  that  shall  be  given  cannot  be  accurately 
stated;  they  must  be  given  in  large  doses,  large  enough  to  accomplish 
the  end  desired.  Without  these  two  agents  to  apply,  the  sufferings 
of  those  who  are  there  to  minister  would  be  second  only  to  those  of 
the  patient. 

Other  drugs  that  have  been  recommended  are  hyoscine  hydrobromide 
gr.  1/100  and  cocaine  applied  to  the  larynx. 

Attendants,  while  in  no  great  danger,  still  should  remember  that 
the  patient  may  be  a  source  of  infection  through  his  saliva  and  should 
take  precaution  to  protect  themselves  by  the  wearing  of  gloves,  cauter- 
ization of  superficial  wounds  contaminated  and  restraint  of  patient 
during  his  maniacal  periods.  One  can  conceive  the  necessity  of  im- 
munization of  an  attendant  accidentally  wounded  by  a  patient  in 
delirium. 

It  would  seen  logical  to  use  the  serum  of  an  immunized  animal  during 
the  attack,  but  its  use  has  proven  in  every  instance  useless. 

Prophylaxis.  That  such  a  disease,  when  preventable,  should  exist 
at  all  within  the  borders  of  a  State  would  seem  to  be  a  distinct  crime 
against  its  members.  That  it  does  exist  in  civilized  communities  is 
largely  due  to  the  difficulty  of  grasping  the  just  relationship  between 
communal  and  individual  rights. 

As  the  disease  is  nearly  always  conveyed  to  man  by  the  dog,  stamp- 
ing the  disease  out  among  dogs  practically  excludes  it  in  a  community. 
The  means  to  accomplish  it  are  so  simple,  the  inconvenience  so  slight 
compared  with  the  results,  that  it  seems  amazing  that  enough  opposition 
should  be  found  to  defeat  legislative  efforts  to  that  end,  and  yet  such  is 
the  fact. 

Among  the  measures  advised  to  accomplish  this  end  are 

Quarantine.  In  Australia,  where  rabies  is  unknown,  the  fact  is 
attributed  to  a  law  making  a  quarantine  for  six  months  for  all  dogs 
brought  into  the  country  imperative. 

Muzzling.  Great  Britain  has  succeeded  in  eliminating  rabies  from 
its  confines  by  an  efficient  muzzling  law. 

This  can  be  effected  by  muzzling  all  dogs  at  large  for  at  least  six 
months  after  the  last  case  of  rabies  in  the  community  or  its  immediate 
environments. 

Less  drastic  and  less  useful  is  the  use  of  the  leash. 

Detention.  Valuable  but  less  thorough,  is  the  detention,  under 
observation  for  three  or  six  months  of  dogs  thought  to  have  been  in 
contact  with  rabid  dogs. 

Licensing.  A  law  to  license  all  dogs  with  destruction  of  the  un- 
licensed, lessening  the  number  of  dogs  by  high  tax  and  primitive  meas- 


708  TREATMENT  OF  ACUTE  INFECTIOUS  DISEASES 

ures,  such  as  holding  the  owner  responsibly  for  damages  done  by  the 
rabid  animal.  These  latter  measures  but  provoke  resentment. 

What  is  needed  is  a  campaign  of  education  in  the  problem  to  lay 
the  path  to  legislation  for  quarantine  or  muzzling  with  compulsory 
reporting  of  cases  and  killing  of  all  animals  bitten  by  rabid  dogs. 

Rabies  in  This  Country.  That  the  laws  against  rabies  is  in- 
efficient is  shown  by  the  increase  in  numbers  and  distribution  of  cases. 
Of  course,  the  States  as  independent  legislative  units,  have  met  the 
problem  differently  and  more  or  less  satisfactorily. 

In  1908  Kerr  and  Stimson,  under  the  U.  S.  Public  Health  and  Marine 
Hospital  Service,  collected  1500  cases  who  applied  for  Pasteur  treat- 
ment that  year  from  thirty  States,  and  534  infected  localities. 

There  were  111  deaths. 

All  were  from  the  Eastern  three-fourths  of  the  country,  none  in  the 
Rocky  Mountains  and  Pacific  Slope. 

Three  years  later,  1911,  Albert  reported  4625  persons  receiving 
treatment  from  1381  infected  localities. 

Moreover  his  report  showed  the  invasion  of  the  Western  quarter 
of  the  country,  where  in  some  localities  it  was  believed  the  spread  was 
due  to  skunks. 

Finally  the  incidence  of  cases  by  States  was  determined  by  the  more 
or  less  efficient  measures  adopted  for  the  regulation  or  stamping  out  of 
the  disease. 

SUMMARY 

When  a  man  is  bitten  by  an  animal  suspected  of  rabies. 

1.  Treat  the  wound. 

2.  Confirm  the  suspicion. 

3.  Institute  antirabic  or  Pasteur  treatment. 

Treatment  of  the  wound. 

Lay  wound  open  thoroughly. 

Encourage  bleeding. 

Wash  thoroughly. 

Bathe  in  antiseptic,  e.  g.,  1-1000  bichloride. 

Wipe  dry. 

Cauterize. 

Best  caustic  is  fuming  nitric  acid;  apply  on  a  glass  rod  or  other  suitable 

applicator,  searching  every  part  of  the  wound. 
If  pain  prevents  thoroughness,  give  an  anesthetic,  general  or  local. 
Then  wash  the  wound  with  physiological  salt  solution,  3i~0i  (4  Gm.- 

500  c.c.),  or  with  a  saturated  solution  of  bicarbonate  of  soda  and 

with  alcohol. 
Phenol,  95  per  cent.,  or  tincture  of  iodine  may  be  used  as  caustic  in 

same  manner  as  nitric  acid,  but  is  not  so  good. 


RABIES  709 

When  phenol  is  used  remove  the  excess  of  carbolic  acid  by  swabbing 

with  absolute  alcohol. 
Method  of  Bloodgood  and  McGlannan. 

Use  first  phenol,  95  per  cent.,  then  fuming  nitric  acid,  then  wash 
wound  with  saturated  solution  of  bicarbonate  of  soda. 

Five  per  cent,  formaldehyde  applied  twelve  hours  (Gumming). 
Actual  cautery. 
Apply  dry  dressing. 

Do  not  use  silver  nitrate  for  cauterizing. 
Suppurating  wounds  dressed  like  those  from  other  causes. 
Keep  open  and  drain. 

Old  bites. 

Remove  scabs. 

Clean  wound. 

Cauterize  as  above. 

Excise  area  of  scab. 

Treat  as  open  wound. 

In  wound  of  extremity,  if  fresh,  a  tourniquet  may  be  applied  until 

the  wound  can  be  cauterized. 
Confirm  suspicion.    (See  text.) 

Prevention.    Antirabic  or  Pasteur  Treatment    (See  text.) 

Treatment  of  developed  case. 

Fatal  issue  is  certain;  hence,  treatment  is  palliative  to  lessen  suffer- 
ing and  smooth  the  way  to  the  end. 

Room. 

Must  be  quiet,  avoiding  even  talking  and  all  unnecessary  handling. 
Avoid  all  draughts  of  air;  may  be  necessary  to  stuff  chinks  in  win- 
dows. 

Diet. 
Concentrated  and  suggest  fluid  as  little  as  possible,  e.  g.,  ice-cream, 

custard,  junket. 
Thirst  is  intense. 
Can  only  be  relieved  by  enemata  or  Murphy  drip  method. 

To  lessen  nerve  irritability. 

Early  stages. 

Chloral  and  bromides,  large  doses. 

Chloral,  gr.  xxx  to  gr.  Ix  (2-4  Gm.)  by  rectum  (adult). 
Bromides. 
Combine  with  chloral  in  double  the  dose  of  the  chloral.    Give  by 

rectum  in  warm  milk  gii-iii  (60-90  c.c.). 

Convulsions. 

Chloroform  inhalations. 
Morphine  hypodermically. 


710  TREATMENT  OF  ACUTE  INFECTIOUS  DISEASES 

Amounts  must  be  sufficient  to  accomplish  desired  results. 

Cocaine  to  larynx. 

Hyoscine  hydrobromide,  gr.  1/100. 

4- 

Maniacal  periods. 

Restraint. 

Attendants  must  remember  that  patient's  saliva  is  infectious. 
Should  wear  glasses. 

Should  cauterize  superficial  wounds  contaminated. 
Should  undergo  preventive  treatment  if  wounded  by  patient. 

Prophylaxis. 

Enlightened  laws  and  Health  Board  regulations. 
Quarantine. 

Six  months  for  all  dogs  brought  into  country  (Australia) . 
Muzzling. 

All  dogs  muzzled  for  six  months  after  a  case  of  rabies  (Great  Britain) . 
Less  drastic  and  less  effectual. 

Use  of  leash. 

Detention  for  three  to  six  months  of  dogs  in  contact  with  rabid 
dogs. 

Destruction  of  unlicensed  dogs. 
Public  education. 


CHAPTER  XL 

TETANUS 

TETANUS  is  a  disease  due  to  the  action  of  an  organism  first  described 
by  Nicolaier  in  1884  and  named  Bacillus  tetani.  The  symptoms  of  the 
disease  are  effected  by  the  operation  of  a  toxin  elaborated  by  the  organ- 
ism, carried  to  a  distance  from  the  site  of  infection,  entering  into  and 
acting  upon  nerve  tissue  for  which  it  has  a  striking  affinity.  In  this 
the  Bacillus  tetani  is  like  the  Bacillus  diphtheriae. 

The  toxin  affects  the  motor  end  plates  of  the  nerves,  travels  by  way 
of  the  axis  cylinders  to  the  spinal  cord  and  motor  nuclei  at  the  base  of 
the  brain  and  arriving  here,  and  only  when  arriving  here,  induces  by  its 
irritating  effects  on  these  centres  the  characteristic  symptoms  of  the 
disease. 

If  the  infecting  wound  brings  the  toxin  at  once  into  intimate  contact 
with  motor  end  plates  as  a  wound  of  a  muscle  of  the  leg,  the  absorption 
of  the  nerve  supplying  that  muscle  will  be  facilitated  and  evidences  of 
the  disease  will  be  manifested  in  this  extremity  first;  hence,  is  called 
" local  tetanus"  and  as  the  other  nerves  more  remote  from  the  site  of 
the  wound  are  affected  the  symptoms  seem  to  advance  up  the  body; 
hence,  it  is  called  tetanus  ascendens,  but  if  the  wound  is  in  the  sub- 
cutaneous tissue,  as  it  usually  is  in  man,  as  Ashurst  and  John  explain, 
the  toxins,  diffused  by  way  of  the  lymph  channels,  act  on  all  motor  end 
plates  practically  simultaneously  and  those  centres  sending  out  the 
shorter  nerves  would  actually  be  reached  earliest;  hence  symptoms 
would  appear  in  the  territory  of  the  short  facial  nerves  with  early 
trismus  and  in  the  longer  nerves  later,  hence,  Tetanus  descendens. 

The  toxin  in  all  probability  also  spreads  along  the  cord  when  carried 
there  by  way  of  the  nerve  trunks  or  by  way  of  the  general  circulation. 

The  sensory  as  well  as  the  motor  side  of  the  cord  is  affected  and 
the  irritability  of  the  reflexes  heightened. 

Incubation.  After  the  infection  some  little  time  must  elapse  between 
the  invasion  of  the  tissue  by  the  bacillus  and  the  arrival  of  the  toxins 
at  the  centres.  This  will  depend  on  the  activity  of  the  germ  in  the  wound 
and  the  facility  of  transportation  for  the  toxins;  for  example,  the  length 
of  the  nerve  trunk  travelled. 

The  average  time  is  seven  to  nine  days.  Under  nine  days  cases  are 
called  acute,  over  nine  days  chronic.  Spores  may  lie  for  some  time  in 


712  TREATMENT  OF  ACUTE  INFECTIOUS  DISEASES 

the  tissues  before  they  mature  and  thus  the  incubation  period  be  length- 
ened to  weeks  or  even  months. 

It  is  believed  that  the  invasion  by  pyogenic  organisms  of  .the  tissues 
in  which  the  spores  lie  hastens  the  maturation  of  the  spores. 

Prophylactic  injections  of  antitoxin,  if  it  does  not  entirely  prevent 
the  development  of  the  disease,  materially  lengthens  the  incubation 
period. 

The  symptoms  of  this  disease,  then,  are  attributable  to  the  heightened 
and  uncontrolled  operation  of  the  motor  centres  under  the  whip  of  the 
toxins,  and  show  first  and  most  marked  in  the  territory  of  those  nerve 
centres  first  and  most  affected. 

The  prodomata  occur  a  day  or  two  after  infection  and  are  character- 
ized by  restlessness,  sleeplessness,  sometimes  headache,  giddiness  and 
excessive  yawning  and  there  may  be  difficulty  in  urination  due  to  spasm 
of  the  sphincter  muscle  of  the  bladder. 

Then  follows  trismus  (lockjaw)  and  spasms  of  the  facial  muscles 
giving  rise  to  the  so-called  risus  sardonicus.  Stiffness  of  muscles  of  neck 
with  retraction;  of  the  muscles  of  the  back  with  opisthotonus;  of  the 
abdomen;  curiously  enough  the  muscles  of  the  arms  often  escape. 

There  may  be  dyspnoea  and  cyanosis  due  to  the  spasm  of  the 
diaphragm  and  respiratory  muscles. 

These  contractions  are  tonic  and  continuous,  interrupted  by  clonic 
convulsions,  often  severe  and  painful,  which  are  induced  by  slight 
irritations. 

Moderate  fever  obtains,  sometimes  becoming  hyperpyrexia,  espe- 
cially, near  the  end. 

Sometimes  the  disease  is  restricted  to  that  part  of  the  cord  supplying 
the  part  wounded.  It  may  show  itself  as  trismus,  rigidity  or  spasm  of 
a  limb  and  not  infrequently  pain  about  the  wound  or  there  may  be 
spasm  of  the  throat  muscle.  Such  localized  tetanus  may  be  seen  in 
those  partially  protected  by  prophylactic  injections. 

Treatment  of  the  Developed  Disease.  It  is  to  be  regretted  that 
the  use  of  " specifics"  has  too  often  invited  the  thoughtless  to  an  undue 
reliance  on  them  and  to  a  failure  of  consideration  for  equally  important 
measures. 

Certain  measures  aiming  at  the  conservation  of  the  patient's  energies 
in  his  struggle  to  subdue  the  infection  such  as  bodily  and  mental  rest, 
the  meeting  of  energy  demands  through  food  intake,  and  careful  nursing 
are  such  important  measures. 

Room.  A  well  ventilated  room  as  remote  as  possible  from  the 
noises  of  the  street  or  the  rest  of  the  household  should  be  chosen;  this 
Should  be  somewhat  darkened.  The  exquisite  sensitiveness  of  the 


TETANUS  713 

sensory-motor  apparatus  has  to  be  kept  in  mind  and  the  ease  with 
which  slight  stimulation  of  the  same  precipitates  the  distressing  clonic 
spasms;  so,  sudden  noises,  such  as  loud  talking  or  exclamations,  jarring 
of  doors,  windows,  or  heavy  tread,  moving  of  furniture,  are  to  be  care- 
fully avoided.  Cotton  may  be  put  in  the  ears. 

The  bed  is  best  of  the  hospital  type,  that  is  one  about  which  the  nurse 
can  perform  her  duties  to  the  patient  with  the  least  disturbance  to 
him. 

A  water  bed  may  prove  a  source  of  comfort.  Skilful  nursing  is  re- 
quired to  subserve  the  needs  of  the  body  without  exciting  spasms.  Baths 
should  be  given  by  sponges  and  the  water  be  lukewarm  as  least  likely  to 
provoke  a  shock  and  a  resultant  convulsion. 

Diet.  Feeding  is  a  difficult  task  on  account  of  the  locking  of  the 
jaws  and  the  spasms  of  muscles  the  effort  excites. 

It  is  obvious  that  all  food  must  be  liquid  and  as  concentrated  as 
possible,  as  the  repetition  of  the  act  of  feeding  is  distressing  and  the 
danger  of  aspiration  and  ensuing  pneumonia  is  always  present. 

Milk,  cereal-waters,  eggs  raw,  all  fortified  with  sugar  to  increase 
the  caloric  value  are  suitable. 

So  difficult  is  oral  feeding,  that  rectal  feeding  and  nasal  feeding  are 
sooner  or  later  necessary  as  adjuvants  to  or  substitutes  for  oral  feeding, 
and  even  efforts  at  subcutaneous  feeding  have  been  made.  As  a  nutrient 
enema  Bloodgood  advises  200  c.c.  of  peptonized  milk,  two  eggs  and 
enough  salt  solution,  physiological  (roughly,  3i  to  Oi)  to  make  up  to 
500  c.c.  and  administer  by  the  drop  method  of  Murphy.  (See  Pneu- 
monia, Chap.  IX.) 

One  may  give  the  milk  without  peptonization  and  fortify  with  sugar, 
adding  salt  5i  to  the  pint  (4  Gm.  to  500  c.c.)  and  brandy  or  whiskey. 
For  example  500  c.c.  milk,  sugar  45  grams  and  whiskey  or  brandy  30  c.c. 
would  furnish  600-650  calories.  If  slowly  introduced  the  bowel  may  be 
made  to  retain  this  amount  and  in  this  the  spasm  of  the  sphincter  may 
assist.  Nasal  feeding  is  done  by  passing  a  small  flexible  rubber  tube 
through  the  nostrils  into  the  stomach. 

To  lessen  or  overcome  the  spasm  that  blocks  the  passage  of  the  tube 
morphine  in  doses  of  the  sulphate  gr.  1/8  to  gr.  1/4  (0.008-0.015  Gm.) 
hypodermically  may  be  given  beforehand  or  chloroform  may  be  used 
during  the  procedure. 

While  little  reliance  can  be  put  on  subcutaneous  feeding,  olive  oil 
has  been  used  and  solutions  of  glucose,  5  per  cent,  to  10  per  cent. 

Park  mentions  the  use  of  normal  horse  serum,  saying  that  500-1,000 
c.c.  can  be  given.  The  tissues  are  in  much  need  of  water,  which  can  be 
supplied  best  perhaps  as  a  saline  solution  by  the  drop  method.  A  pint 


714  TREATMENT  OF  ACUTE  INFECTIOUS  DISEASES 

(500  c.c.)  may  be  given  four  times  a  day.?  Fluid  can  also  be  given 
subcutaneously,  but  with  the  extreme  irritability  of  the  nerve  structures 
it  is  not  a  good  method  in  this  disease. 

Bowels.  When  seen  early  a  saline  can  and  should  be  given;  later 
one  has  recourse  to  enemata. 

Obstinate  constipation  usually  obtains  after  the  disease  has  once 
begun. 

Urine.  Watchfulness  to  detect  the  retention  of  urine  that  may 
occur  is  necessary  and  its  retention  entails  the  Use  of  the 
catheter. 

The  second  consideration  is  the  elimination  of  the  focus  of 
infection  so  far  as  possible.  This  is  accomplished  by  rigorous  local 
treatment.  The  wound  should  be  treated  on  surgical  principles,  laid 
wide  open,  sloughing  material  removed,  packed  and  allowed  to  heal  by 
granulation.  Ashurst  and  John  advise  swabbing  the  wound  with  3  per 
cent,  alcoholic  solution  of  iodine,  followed  by  hydrogen  peroxide  and 
packing  with  gauze  saturated  with  the  iodine  solution.  They  say  that 
if  amputation  becomes  necessary  the  wound  of  the  stump  should  be 
left  open  and  treated  in  the  same  way.  It  has  been  advised  to  excise  the 
glands  related  to  the  lymphatic  system  draining  the  affected  area  if  they 
seem  in  any  way  involved.  Cauterization  is  decried  as  favoring  the 
growth  of  the  anaerobic  tetanus  bacilli. 

Some  observers  advocate  the  local  administration  of  dry  tetanus 
antitoxin  to  the  wound  after  it  has  been  surgically  treated  and  this  has 
been  especially  advocated  in  tetanus  neonatorum  in  which  the  infection 
comes  through  the  umbilicus. 

The  antitoxin  which  will  be  given  at  once  as  a  prophylactic  measure 
should  be  introduced  into  the  tissues  around  the  wound  so  as  to  saturate 
these  parts  with  the  antitoxin. 

Specific  Treatment.  The  third  measure  relates  to  a  neutralization 
of  the  toxins  of  the  disease  by  antitoxin.  Unfortunately  the  combina- 
tion of  toxin  with  tissue  has  been  so  completely  effected  before  treat- 
ment is  begun — for  the  symptoms  of  the  disease  do  not  appear  until 
this  combination  takes  place — and  furthermore  the  combination  is  so 
stable  that  results  comparable  to  the  use  of  the  analogous  antitoxin  in 
diphtheria  are  not  obtained.  It  is  the  fact,  however,  that  some  toxin 
is  still  circulating  free  in  the  tissues  to  add  its  further  poisonous  action 
to  the  cells  that  makes  the  use  of  the  antitoxin  imperative,  for  there  is 
evidence  that  time  is  required  after  the  toxin  has  reached  the  nerve  tissue 
for  the  union  to  become  stable,  and  during  this  period  antitoxin  if  given 
in  sufficient  quantity  may  attract  the  toxin  out  of  the  nerve  substance 
into  a  union  with  itself. 


TETANUS  715 

The  Antitoxin.  The  antitoxin  is  elaborated  in  exactly  the  same 
way  as  diphtheria  antitoxin  in  the  horse,  whose  serum  becomes  the 
vehicle  of  its  administration. 

The  unit  adopted  in  this  country  is  about  ten  times  the  size  of  the 
diphtheria  antitoxin  unit.  (See  Diphtheria,  Chap.  XVIII.) 

Use  of  Antitoxin.  Our  efforts  are  aimed  at  getting  the  antitoxin 
in  contact  with  the  toxins  both  while  circulating  free  and  when  in  loose 
combination  with  nerve  tissue.  These  efforts  are  effected  by  giving  the 
antitoxin  into  the  subcutaneous  tissue  and  into  the  vein  to  secure  the 
first  result  and  into  the  cord,  into  the  nerve  trunk,  into  the  brain  and 
into  the  muscle  about  the  end  plates  to  secure  the  second  result.  Of 
these  routes  the  intravenous,  the  intra-spinal  and  intra-neural  are  the 
important. 

It  cannot  be  too  emphatically  insisted  that  if  results  are  to  be  ob- 
tained from  the  use  of  antitoxin  it  should  be  administered  as  soon  as 
possible  after  symptoms  are  evident. 

Subcutaneously.  So  readily  is  this  procedure  carried  out  in  compari- 
son with  the  others  that  I  feel  it  incumbent  on  me  to  emphasize  the 
teaching  of  the  able  workers  in  this  field  relative  to  the  efficiency  of  the 
specific  when  so  administered.  Park  hi  his  article  in  Forchheimer's 
Therapeusis  in  Internal  Diseases  says:  "A  subcutaneous  injection  is  not 
wholly  absorbed  for  three  days.  The  water  holding  the  antitoxin  in 
solution  is  quickly  absorbed,  but  the  antitoxin  is  held  back.  At  the  end 
of  six  hours  only  10  per  cent.,  twenty-four  hours  35  per  cent.,  forty-eight 
hours  65  per  cent.,  and  at  seventy-two  hours  and  ninety-six  hours  100 
per  cent." 

In  a  study  on  man  injected  subcutaneously  as  when  given  under  the 
skin  with  10,000  units  Park  found  the  highest  antitoxin  content  of  the 
blood  at  the  end  of  forty-eight  and  seventy-two  hours  amounting  to  1 
unit  per  c.c. 

He  goes  on  to  say  that  when  given  into  a  muscle  the  absorption  is 
three  times  as  fast,  being  accomplished  in  twenty-four  hours  but  even 
here  the  absorption  is  uncertain  and  not  comparable  with  the  intravenous 
method. 

Dosage.  It  can  readily  be  seen  that  because  of  the  slowness  of 
absorption  and  its  great  dilution  in  the  blood,  lymph  and  tissue  juices, 
little  can  be  expected  of  it  unless  administered  in  massive  doses.  These 
doses  are  limited  only  by  the  expense  entailed  in  their  purchase.  Over 
100,000  units  in  six  hours  have  been  advised,  15,000  and  more  every 
three  hours  and  in  one  case  actually  224,000  units  were  given  in  three 
days,  happily  with  recovery. 

It  can  only  be  said  that  this  route  should  never  be  preferred  to  the 


716  TREATMENT  OF  ACUTE  INFECTIOUS  DISEASES 

vein  if  it  is  possible  to  get  into  the  latter;  if  not,  the  muscle  should  be 
preferred  to  the  subcutaneous  tissue. 

Intra-muscular.  As  has  been  said,  this  route  is  better  than  the 
subcutaneous,  but,  never  should  be  chosen  over  the  vein.  Its  use  in 
the  muscle  about  the  site  of  the  wound  to  attack  the  toxin  at  the  end 
plates  has  another  purpose. 

Intravenous  Injections.  This  method  assures  rapid  contact  of 
antitoxin  with  such  toxins  as  are  still  circulating  free  in  the  fluids  of  the 
body,  while  the  antitoxin  content  of  the  blood  is  more  than  twice  that 
obtainable  by  subcutaneous  injection. 

Dosage.  Even  by  this  method  the  dose  should  be  large  and  it  must 
be  remembered  that  the  efficacy  of  a  given  dose  is  multiplied  many 
fold  by  being  administered  early.  At  the  first  suspicion  of  the  condition 
the  serum  should  be  administered. 

The  dose  recommended  is  10,000  to  15,000  units  once  or  twice  in 
twenty-four  hours,  and  this  large  dose  because,  as  Park  says,  though 
it  is  many  times  more  than  enough  to  neutralize  the  toxins  present  in 
the  blood,  the  antitoxin  experiences  difficulties  in  passing  from  the  blood 
to  the  cellular  fluids,  "the  tissue  fluids  only  contain  about  3  per  cent,  of 
the  antitoxic  content  of  the  blood."  (Park.) 

It  has  been  advised  to  give  one  large  intravenous  dose  to  start  with 
and  smaller  subcutaneous  doses  every  day  or  two  until  symptoms  cease 
or  to  give  lesser  doses  by  the  vein  every  day.  I  should  feel  that  in  so 
dire  a  condition  it  were  wise  to  lean  towards  the  larger  doses  and  shorter 
intervals,  when  the  expense  does  not  forbid,  always  preferring  the 
venous  route. 

Small  children  may  be  given  one-half  the  dose  and  infants  one-quarter. 
Park  recommends  as  "a  good  working  rule,"  2,000  units  for  every  ten 
pounds  of  patient. 

In  very  young  children  and  infants  where  the  intravenous  route  is 
impossible,  the  intramuscular  route  is  the  necessary  method. 

Perhaps  if  only  one  method  of  administration  could  be  used  the 
intravenous  would  prove  the  best,  and  in  practice  it  should  be  given 
preference  as  a  means  of  getting  antitoxin  into  the  body  fluids,  while  as 
important  adjuvants  to  its  operation  methods  of  bringing  the  antitoxin 
into  direct  contact  with  nerve  tissue  should  be  sought. 

These  methods  are  the  intra-spinal,  the  intra-neural,  the  intra- 
cerebral  and  the  intra-muscular  at  the  seat  of  the  wound. 

Intra-spinal.  This  is  called  the  best  method  by  Park  and  with 
this  I  heartily  concur.  It  is  conceived  that  the  serum  so  given  will 
come  into  more  immediate  contact  with  spinal  centres  and  that  the 
more  likely  if  the  cord  or  cauda  is  wounded  by  the  needle.  It 


TETANUS  717 

has  been  thought,  too,  to  diffuse  readily  into  the  blood  stream  from 
the  cerebro-spinal  fluids. 

The  dose  should  be  3,000  to  5,000  to  10,000  units  (6  to  20  c.c.)  each 
day  until  improvement  sets  in.  For  table  of  amounts  to  be  injected, 
consult  table  of  Sophian.  (See  Cerebro-spinal  Meningitis,  Chap.  XXV.) 

The  technique  is  that  of  the  administration  of  cerebro-spinal  menin- 
gitis serum.  (See  Cerebro-spinal  Meningitis,  Chap.  XXV.)  One  should 
combine  the  intravenous  and  intra-muscular  method  with  it. 

Intra-neural.  Of  late  an  especial  plea  has  been  made  for  intra- 
neural  injections.  It  is  claimed  on  the  basis  of  experimentation  that 
antitoxin  injected  into  the  nerve  travels  like  toxin  by  way  of  the  nerve 
to  its  centres  to  operate  on  the  toxins  there.  The  large  trunks  leading 
from  the  wounded  area  are  selected  and  injected  at  a  site  as  near  the 
cord  as  is  feasible  to  expose  them.  The  sciatic,  the  anterior  crural,  the 
obturator  and  cauda  equina  have  been  injected  in  the  lower  half  of  the 
body,  while  the  strands  of  the  cervical  plexus,  the  hypoglossal  and 
spinal  accessory  are  legitimate  points  of  attack  in  the  upper  half. 

Ashurst  and  Jones  have  put  as  much  as  1,500  units  into  the  sciatic 
nerve  and  750  into  the  anterior  crural. 

If  injected  slowly  much  is  absorbed  into  the  nerve  trunk. 

The  disadvantage  is  the  nicety  of  surgical  procedure  demanded. 
It  must  be  remembered  that  this  is  only  an  adjuvant  method  and  that 
the  other  nerves  have  to  be  reached  by  other  methods. 

This  method  was  not  adopted  in  the  work  in  the  late  war. 

Intra-cerebral.  This  method  was  early  tried,  but  the  results  seem 
to  be  so  little  encouraging  and  the  dangers  and  sequelae  of  the  pro- 
cedure so  considerable  that  I  am  inclined  to  advise  against  it. 

Intra-muscular.  Injections  of  antitoxin  may  be  made  about  the 
wound,  into  the  muscles  to  bring  the  serum  in  contact  with  the  motor 
end  plates  to  be  first  affected. 

The  instructions  of  the  Board  of  Health  of  New  York  City  are  to  give 
3,000  to  5,000  units  of  the  antitoxin  intraspinally  by  the  gravity  method. 
This  may  be  diluted  with  sterile  saline  making  the  total  volume  to  at 
least  5  c.c.  An  intravenous  injection  of  10,000  units  should  be  given 
at  the  same  time  to  render  the  blood  antitoxic  for  four  or  five  days. 
At  the  end  of  24  and  48  hours,  repeat  the  intraspinal  injection.  At  the 
end  of  72  hours  (4th  day)  give  a  subcutaneous  dose  of  5000  units. 

They  furthermore  advise  that  if  the  intraspinal  dose  cannot  for  any 
reason  be  given  increase  the  dose  to  15,000  to  20,000  intravenously. 
If  neither  of  these  methods  is  possible  give  at  once  an  intramuscular 
dose  of  20,000  units  or  more. 

The  experience  in  the  late  war  has  afforded  an  unparalleled  opportu- 


718 


TREATMENT  OF  ACUTE  INFECTIOUS  DISEASES 


nity  for  the.  study  of  this  disease  and  of  the,  efficacy  of  antitoxin  in  its 
treatment.  The  following  table,  taken  "from  Fitzgerald's  article  in 
Nelson's  Loose  Leaf  Living  Medicine,  is  an  outline  of  the  treatment 
suggested  by  the  Tetanus  Committee  of  the  War  Office: 


Day 

Subcutaneous 

Intramus- 
cular 

Intraspinal 
(intraihecal) 

1st  day 

8000 

16000 

2dday 

8000 

16000 

3d  day 

4000 

4th  day 

4,000 

5th  day 

2,000-4,000 

7th  day 

2,000-4,000 

9th  day 

2.000-4.000 

To  get  the  best  results  this  should  be  supplemented  by  intravenous 
injections  in  large  doses  and  the  rule  proposed  by  Park  is  an  excellent 
one  to  follow;  i.  e.,  2,000  units  per  ten  pounds  of  patient.  This  will 
guarantee  a  high  antitoxic  content  in  the  blood  for  four  or  five  days. 

Local  Tetanus.  In  local  tetanus,  antitoxin  is  used  by  the  intramus- 
cular and  subcutaneous  methods  and  need  not  be  given  intraspinally. 

Drug  Treatment  of  the  Disease.  All  such  treatment  is  empirical, 
having  the  weakest  kind  of  basis. 

Such,  for  example,  is  the  use  of  Phenol  (Carbolic  Acid). 

This  method  was  introduced  by  the  Italian,  Bacelli,  and  its  usage 
has  followed  his  recommendations  with  slight  modifications  as  to  dosage 
and  concentration.  He  gave  0.30-0.50  grams  (gr.  v-viiss.)  a  day. 
It  may  be  given  in  1/2,  1,  2  or  3  per  cent,  watery  solution  and  has  been 
used  in  oil  5  per  cent. 

It  is  given  hypodermically  and  at  frequent  intervals  hourly  or  every 
two  hours.  An  injection  of  m.  xx  of  a  2  per  cent,  solution  at  two-hour 
intervals  would  give  about  5  grains  a  day;  to  increase  the  dose  one 
may  make  the  intervals  shorter  or  the  solution  stronger,  as  3  per  cent., 
which  in  same  amounts  and  intervals  gives  about  7  grains. 

One  should  remember  that  if  antitoxin  is  given  at  the  same  time  it 
contains  as  a  preservative  5  per  cent,  trikresol  probably  operative  in 
the  same  direction.  Evidences  of  poisoning  by  inspection  of  the  urine 
(smoky  urine)  should  be  sought  for,  but  the  body  seems  to  be  peculiarly 
tolerant  in  tetanus. 

The  statistics  seem  too  good  to  be  true  and  especially  in  the  ab- 
sence of  experimental  corroboration. 

When,  however,  antitoxin  is  not  at  hand  or  in  insufficient  quantity, 
phenol  should  be  used. 


TETANUS  719 

DRUGS  IN  THE  TREATMENT  OF  THE  SYMPTOMS 

The  most  urgent  symptom  is  the  convulsion,  because  of  the  great 
exhaustion  it  entails  and  because  of  the  fatal  spasms  that  may  occur. 
There  are  two  classes  of  drugs  used  for  this  purpose,  one  to  lessen  the 
irritability  of  the  centres,  lessen  the  severity  of  the  tonic  contractions 
and  frequency  of  the  clonic,  a  milder  group;  and  the  other  more  im- 
perative, quelling  the  convulsion.  Among  the  first  belong  bromides 
and  chloral,  the  most  important  and  mentioned  together  because  they 
should  be  used  together  to  get  the  best  effects. 

Large  doses  should  be  used;  for  the  pharmacological  depressing  ef- 
fect on  the  spinal  centres  is  sought  and  the  condition  for  which  they 
are  used  a  thousand  times  more  menacing  than  their  toxic  effects  on 
circulation  or  respiration. 

Chloral  should  be  given  in  doses  of  gr.  xv  (1  Gm.)  every  three  hours 
or  gr.  xxx  (2  Gm.)  every  six  hours  increased  to  gr.  xlv  (3  Gm.)  and  gr. 
Ix  (4  Gm.)  every  six  hours,  if  the  spasm  is  severe,  and  heart  and  respira- 
tion are  watched.  Bromides  may  be  given  at  double  the  chloral  dose, 
as  potassium  bromide  or  mixed  potassium,  sodium  and  ammonium 
bromide,  at  the  same  time  or  in  the  intervals. 

These  are  adult  doses  and  should  be  correspondingly  decreased  for 
children.  They  may  be  given  by  mouth  through  nasal  or  stomach 
tube  if  necessary  or  by  rectum,  milk  furnishing  in  the  latter  method  a 
good  menstruum. 

Among  other  drugs  belonging  to  this  group  but  less  reliable  are 
atropine,  hyoscine,  physostigma  and  chloretone. 

Standing  between  groups  one  and  two  is  a  very  valuable  drug. 

Morphine.  This  drug  not  only  lessens  the  spasm,  but  it  relieves 
pain,  induces  sleep,  and  given  before  any  disturbing  procedure  such  as 
dressing  the  wound,  giving  enemas  or  rectal  feeding,  passing  nasal 
tube  or  catheter  makes  the  procedure  less  trying  and  less  provocative 
of  spasm.  The  doses  should  be  large,  gr.  1/4  to  gr.  1/3  (0.015-0.02  Gm.), 
up  to  gr.  iss.  or  gr.  ii  (0.1  or  0.125  Gm.)  of  the  sulphate  a  day.  Atropine 
sulphate  is  well  combined  with  it. 

The  severity  of  the  clonic  spasms  and  the  suffering  they  sometimes 
entail  demand  more  dominant  measures  such  as  are  furnished  by  the 
second  group  of  drugs;  namely 

Chloroform.  This  is  given  by  inhalation  during  the  exacerba- 
tions of  the  spasms.  It  has  been  used  continuously  over  .periods  of 
hours  and  days,  but  it  is  the  conviction  of  some  observers  that  such 
usage  constitutes  a  danger  in  itself. 

Magnesium  Sulphate.    Intra-spinal.    A  method  suggested  by 


720  TREATMENT  OF  ACUTE  INFECTIOUS  DISEASES 

Meltzer  of  .utilizing  the  depressant  effect^  of  magnesium  sulphate 
when  brought  into  direct  contact  with  the  cord  was  eagerly  seized  upon, 
but  was  found  to  possess  dangers  of  its  own;  however,  the  severity  of 
the  spasms,  pain  and  exhaustion  may  be  such  as  to  make  the  measure 
in  spite  of  its  attendant  dangers  advisable,  but  it  certainly  is  not  to  be 
undertaken  lightly. 

A  25  per  cent,  watery  solution  of  magnesium  sulphate  is  used.  The 
dose  1  c.c.  to  every  25  pounds  of  the  patient's  weight,  discounting 
somewhat  for  the  very  obese  and  large  of  frame. 

The  spinal  puncture  is  made  as  for  an  exploration  (see  Cerebro- 
spinal  Meningitis,  Chap.  XXV),  except  that  the  shoulders  should  be 
somewhat  raised  to  prevent  rapid  diffusion  of  the  solution  upwards 
towards  vital  centres. 

The  needle  should  withdraw  an  amount  of  cerebro-spinal  fluid  equal 
to  that  amount  of  solution  to  be  used,  the  syringe  then  attached  to  the 
needle  and  the  salt  introduced  slowly. 

The  spasms  disappear  and  do  not  recur  for  hours  or  sometimes  days. 
A  recurrence  of  severe  type  would  indicate  a  repetition  of  the  procedure. 
The  danger  lies  in  respiratory  collapse. 

The  patient  should  be  under  competent  observation  during  the  few 
hours  after  the  injection  and  artificial  respiration  and  stimulation 
undertaken  if  necessary,  and  it  would  seem  advisable  to  withdraw  what 
magnesium  sulphate  may  be  left  in  the  canal. 

DRUGS  OF  MORE  DOUBTFUL  VALUE 

Chloretone.  This  drug  in  whiskey  by  mouth  or  olive  oil  by  rectum 
has  been  used  in  doses  of  gr.  xxx  (2  Gm.)  every  two  hours  until  the 
patient  sleeps.  Even  doses  as  high  as  66  and  75  grains  (5  Gm.)  have 
been  advised. 

Atr opine.  This  drug  is  used  in  combination  with  morphine  or 
alone  to  lessen  the  spasm  and  as  Bloodgood  says  finds  its  principal 
value  in  the  prevention  and  relief  of  the  distress  due  to  an  oversecre- 
tion  of  mucus  in  the  air  passages.  The  dose  of  the  sulphate  should  be 
gr.  1/100  to  gr.  1/25  (0.0006-0.0025  Gm.)  into  the  contracted  muscles. 

It  can  be  repeated  at  four-hour  intervals  up  to  the  well-known  physi- 
ological limit. — dilated  pupils — excessive  dryness  of  mucous  membranes 
or  rash. 

Hyoscine.  This  drug,  like  atropine  derived  from  the  solanacese 
acts  like  atropine  to  lessen  spasm  but  is  more  depressing  to  the  cbrti- 
cal  centres  and  in  so  far  is  a  desideratum,  but  it  is  also  depressing  to  the 
respiratory  and  cardiac  centres  and  so  has  to  be  watched  with  care. 


TETANUS  721 

It  may  be  given  as  the  hydrobromide  in  doses  of  gr.  1/100  (0.0006  Gm.) 
twice  a  day. 

Phy  so  stigma  or  calabar  bean,  best  in  the  shape  of  its  active  prin- 
ciple, physostigmine  sulphate,  has  also  been  administered  hypoder- 
mically  in  doses  of  gr.  1/6  (0.01  Gm.)  every  three  or  four  hours.  Diarrhea 
or  muscular  twitching,  if  it  can  be  made  out  during  the  tonic  contrac- 
tions, indicates  the  physiological  limit  and  interruption  of  its  adminis- 
tration. 

Circulatory  stimulants  may  be  indicated  in  the  exhaustion  follow- 
ing clonic  spasms. 

Causes  of  Death.     1.  Spasm  of  the  larynx  with  ensuing  asphyxia. 

2.  Spasm  of  the  respiratory  muscles,  intercostals  and  diaphragm 
with  asphyxia. 

3.  Cardiac  failure. 

4.  Starvation. 

5.  Hyperpyrexia. 

If  the  patient  survives  there  may  be  some  muscular  stiffness  for 
a  long  time  after  the  subsidence  of  the  attack. 

Prognosis.  The  longer  the  incubation  period  the  better  is  the 
prognosis  and  the  longer  the  symptoms  have  continued  the  better  is 
the  eventual  outlook;  that  is,  fatal  cases  are  likely  to  be  shortly  fatal, 
or  in  other  words  the  prognosis  depends  on  the  severity  of  the  infec- 
tion and  the  resistance  of  the  patient.  Extensively  distributed  spasm 
is  of  bad  omen  and  hyperpyrexia  very  fatal. 

Prognosis  depends  largely  on  the  promptness  and  efficiency  of  the 
treatment  and  especially  the  use  of  antitoxin.  While  here  and  there 
a  man  of  experience  expresses  himself  in  this  way:  "The  mortality  has 
not  been  reduced  by  treatment  save  as  to  prevention"  (Hill  in  Archives 
of  Internal  Medicine,  December  15,  1911),  others,  and  the  majority, 
take  a  more  cheerful  view  of  the  value  of  therapeusis.  Park  says,  "If 
every  case  were  given  an  intravenous  injection  of  antitoxin  at  the  time  of 
diagnosis,  and  treated  well  in  other  respects,  probably  50  per  cent, 
would  recover"  (Forchheimer's  Therapeusis  of  Internal  Diseases,  Vol. 
2),  while  lists  of  statistics  may  be  found  attributing  a  fall  in  mortality 
from  80  per  cent,  to  90  per  cent,  down  to  45  to  30  and  less  per  cent,  under 
antitoxin.  A  series  of  over  200  treated  cases  studied  by  Irons  shows  a 
mortality  of  about  61  per  cent.,  a  drop  of  20  per  cent,  from  the  average 
mortality.  Far  better  results  are  following  the  intra-spinal  method. 

Prophylaxis.  Whatever  disagreement  there  may  be  about  the  effi- 
cacy of  treatment  by  antitoxin  there  is  no  dispute  about  its  value  as 
a  prevention,  though  some  surgeons  believe  that  tetanus  is  a  rare 
complication  in  a  wound  promptly  and  properly  treated. 


722  TREATMENT  OF  ACUTE  INFECTIOUS  DISEASES 

Prophylactic  treatment,  then,  resolves  itself  into  two  lines  of  en- 
deavor. 

1.  Treatment  of  the  wound. 

2.  Antitoxin  administration. 

Treatment  of  the  Wound.  The  first  essential  is  a  knowledge 
of  what  kind  of  wounds  under  what  kind  of  environment  are  likely  to 
result  in  tetanus. 

While  it  is  possible  that  an  infection  under  certain  conditions  may 
originate  in  the  intestinal  canal,  for  their  presence  in  the  intestine  is  not 
a  rare  finding  and  in  hostlers  a  common  one,  or  that  the  bacilli  may  be 
resident  in  the  catgut  used  in  surgical  procedures,  still  the  vast  majority 
come  from  punctured  and  lacerated  wounds  contaminated  by  dirt  from 
barns,  stables,  bites  or  other  wounds  from  horses,  punctured  wounds 
from  nails,  fish  bones  in  garden  soil  or  barnyard  refuse;  lacerations,  by 
farm-yard  implements,  machinery,  gun-shot  wounds,  toy-pistols  and 
giant  crackers.  The  Fourth  of  July  harvest  has  each  year  taken  the 
heaviest  toll  of  any  cause. 

After  cleansing  the  surrounding  parts  and  the  wound  with  green 
soap,  alcohol  and  ether  or  painting  with  tr.  of  iodine,  every  suspected 
wound  then  should  be  laid  wide  open  to  the  very  bottom  by  a  free  in- 
cision, bits  of  dirt,  cloth,  wood  or  powder  removed,  lacerated  shreds 
separated  with  scissors  or  the  wound  area  excised  and  the  wound  treated 
with 

Antiseptics.  For  this  purpose  a  3  per  cent,  alcoholic  solution  of 
iodine  may  be  used  or  liquified  phenol,  followed  by  alcohol.  The  wound 
is  then  loosely  packed  with  the  iodine  solution  and  dressed  daily  after 
irrigation  with  peroxide  of  hydrogen  with  the  gauze  soaked  in  iodine 
solution  or  with  iodoform  gauze.  No  caustic  should  be  used  as  the  germs 
are  anaerobic  and  will  thrive  best  under  the  eschar  produced  by  such 
agents.  The  wounds  should  be  kept  open  and  allowed  to  granulate  from 
the  bottom. 

It  has  been  advised  to  use  powdered  dry  antitoxin  in  the  wound  or 
the  liquid  antitoxin  itself,  applying  a  loose  dressing  over  it.  In  other 
words,  the  wound  is  to  be  treated  by  sound  surgical  methods. 

Use  of  Antitoxin.  This  should  be  given  at  once.  Its  efficacy  is 
best  demonstrated  by  the  fact  that  the  high  death  rate  from  tetanus 
after  Fourth  of  July  wounds  has  been  almost  if  not  quite  wiped  out 
in  those  hospitals  where  it  has  been  used  at  the  time  the  wound  was 
dressed.  Its  use  during  the  late  war  has  placed  its  value  beyond 
dispute. 

Dose.  The  usual  dose  is  1,500  units  given  subcutaneously,  or  better, 
into  the  tissues  and  muscles  about  the  site  of  the  wound,  to  protect  the 


TETANUS  723 

motor  end  plates  at  the  site  of  toxin  formation  first  and  the  remoter 
nerves  next. 

Repetition  of  the  Dose.  It  has  been  shown  that  in  eight  or  ten 
days  all  the  antitoxin  has  been  eliminated  and  for  this  reason  a  second 
dose  of  the  same  amount  should  be  given.  This  second  dose  will  almost 
surely  protect.  Some  cautious  men,  however,  give  a  third  dose  and 
some  continued  doses  at  these  intervals  until  the  wound  is  healing  in  a 
healthy  manner  by  granulation. 

If  for  any  reason  a  wound  has  to  be  opened  up  a  second  time  a  prophy- 
lactic dose  of  1 ,500  units  should  be  given  again  as  the  tetanus  bacilli 
locked  up  in  the  healed  wound  may  become  active  as  a  result  of  the 
procedure.  • 

Some  men  have  relied  on  the  local  use  of  antitoxin  in  the  wound 
as  described;  but,  if  antitoxin  seems  indicated  at  all  it  should  be  given 
as  above  described  except  in  cases  of  local  tetanus,  whether  it  be  used 
locally  or  not. 

The  dosage  in  a  child  may  be  a  little  less,  1,000  units,  but  there  is  no 
objection  and  some  value  in  the  larger  dose. 

Serum  Disease.  Rashes  and  joint  pains  as  after  diphtheria  anti- 
toxin may  appear,  but  are  of  little  importance. 


SUMMARY 

Incubation  time. 
Average  seven  to  nine  days.    May  be  weeks  or  months.    (See  text.) 

Symptoms. 

Due  to  irritation  of  motor  nerves  inducing  tonic  contraction  of 
muscles  interrupted  by  clonic  contractions,  which  are  easily  ex- 
cited by  slight  stimuli. 

Treatment 
Rest. 
Elimination  of  every  stimulus  to  the  highly  irritable  motor  centres. 

Room. 

As  far  away  from  the  noise  of  the  street  and  the  rest  of  the  house- 
hold as  possible. 

Avoid  sudden  noises,  such  as  jarring  of  doors  and  windows,  heavy 
tread  of  feet,  moving  furniture,  loud  talking. 

Cotton  may  be  put  in  the  ears. 

Room  should  be  a  little  darkened. 

Should  be  well  ventilated. 


724  TREATMENT  OF  ACUTE  INFECTIOUS  DISEASES 

Bed. 

Half-bed  of  the  hospital  type,  with  woven  wire  springs,  firm  mat- 
tress, smooth  sheets. 
Water  bed  may  be  more  comfortable. 

Care  of  the  body. 

Baths  should  be  given  of  sponges  of  warm  water  in  a  warm  room,  as 

least  likely  to  provoke  a  convulsion. 
Mouth — best  rinsed  with  clear  warm  water  or  saline  solution,  or  2 

per  cent,  boric  acid  from  time  to  time  unless  it  incites  the  clonic 

contractions. 

Diet. 

Feeding  very  difficult. 

Liquid  foods;  concentrated,  administered  as  infrequently  as  com- 
patible with  body  needs. 

Milk,  cereal  waters,  eggs;  all  fortified  with  sugar. 
Sooner  or  later  rectal  or  nasal  feeding  must  be  used  in  part  or 

wholly. 
Rectal  feeding. 

Two  hundred  c.c.  peptonized  milk. 

Two  eggs. 

Salt  solution  (3i  to  Oi)  (4  Gm.-500  c.c.)  up  to  500  c.c.  or  1  pint 

and  administer  by  the  drop  method  of  Murphy  (Bloodgood) . 
Or  500  c.c.  raw  milk.  1 

Forty-five  grams  milk  sugar.     1 600-650  cals. 
Thirty  c.c.  whiskey  or  brandy,  j 
Introduce  slowly  into  bowel. 
Two  or  three  rectal  feedings  a  day  is  about  all  the  bowel  will  take 

for  any  length  of  time. 
Nasal  feeding. 

Use  small  flexible  tube. 
If  spasm  blocks  the  tube  give 

Morphine  sulphate,  gr.  1/8-gr.  1/4  (0.008-0.015  Gm.) .    (Adult  dose.) 
Subcutaneous  feeding. 
Doubtful  value. 

Olive  oil. 

Glucose,  5  per  cent,  to  10  per  cent,  (real  value). 

Normal  horse  serum,  500-1,000  c.c.  (Park). 

Fluids. 

On  account  of  the  difficulty  of  getting  enough  water  by  the  mouth. 
Give  physiological  salt  solution  (3i  to  Oi  or  4  Gm.  to  500  c.c.)  by 

Murphy  drip  method  by  bowel. 
Give  5  per  cent,  glucose  solution  in  same  quantities  by  drop  method. 

Bowels. 

When  seen  early. 

Saline.    Epsom,  Rochelle  or  Glauber's  salt,  5ss.-53/4  (15-20  Gm.), 
in  half  to  three-quarter  glass  of  water. 


TETANUS  725 

Later. 
Enemata — carefully  given  to  avoid  exciting  spasm. 

Bladder. 
Watch  for  retention;  if  it  occurs  use  catheter.    Precede  by  morphine. 

Eliminate  the  focus  of  infection. 
Wound  laid  wide  open. 
Remove  sloughs. 

Pack  with  gauze,  let  heal  by  granulations. 
Swab  wound  with  3  per  cent,  of  alcoholic  solution  of  iodine,  follow 

with  peroxide  of  hydrogen  and  pack  with  gauze  saturated  with 

the  iodine  solution.    (Ashurst  and  John.) 
Cauterization  should  not  be  done. 

Specific  treatment 
Use  of  antitoxin.     (For  discussion  of  its  limitations  and  the  mode 

of  administration,  see  text.) 
Subcutaneous. 

Absorption  slow,  hence,  greatly  diluted  in  blood;  requires  large 
doses,  limited  only  by  expense,  e.  g.,  100,000  units  in  twenty- 
four  hours,  or 

Fifteen  thousand  every  three  hours. 
Intramuscular. 

Better  than  subcutaneous,  but  not  as  good  as  intravenous. 
Dose,  10,000  to  15,000  units  once  or  twice  in  twenty-four  hours. 
Intravenous.    Better  than  above  but  not  comparable  to  infra-spinal.. 
Can  give  one  large  intravenous  dose  to  begin  with  and  subcutaneous 
or  intramuscular  doses  every  day  or  two  following  or  daily 
intravenous  doses  of  smaller  amounts. 

Park's  rule.    Use  2,000  units  for  each  ten  pounds  body  weight. 
In  addition  antitoxin  should  be  brought  into  more  direct  contact 

with  the  nerve  tissue. 
Intraspinal  always  to  be  used  if  possible. 
Dose,  3,000  to  5,000  to  10,000  units  (6  to  20  c.c.)  daily. 
(For  technique,  see  serum  administration  in  Cerebro-spinal  Men- 
ingitis, Chap.  XXV.) 

For  amounts  consult  Sophian's  tables.    (See  Cerebro-spinal  Men- 
ingitis.) 
Intraneural. 

Into  large  nerve  trunks  leading  from  wounded  area,  as  near  the 
cord  as  feasible  to  expose  them.    (As  much  as  1,500  units  have 
been  put  into  the  sciatic  nerve.)    Not  advised. 
Intracerebral. 

An  early  method.    The  results  have  not  been  encouraging. 
Intramuscular  (at  site  of  wound). 

To  bring  serum  into  contact  with  motor  end  plates  of  wounded 
area. 


726  TREATMENT  OF  ACUTE  INFECTIOUS  DISEASES 

For  New  York  Board  of  Health  method  .pf  combined  intra-spinal, 
intravenous  and  intramuscular  dosage,  see  text. 

For  the  method  of  the  Tetanus  Committee  of  the  United  States 

War  Department,  see  text. 
These  are  the  best  methods. 
Drugs. 

Purely  empirical  usage. 
Phenol  (carbolic  acid). 

Dose,  gr.  v  to  gr.  viiss.  (0.30-^0.50  Gm.)  daily. 

Given  in  2  per  cent,  solution  in  oil. 

M.  xx  (1.30  c.c.)  every  two  hours  would  amount  to  gr.  v  (0.30 

Gm.)  a  day. 

Same  dose  of  3  per  cent,  would  equal  gr.  viiss.  (0.50  Gm.). 
Watch  urine  for  smoky  urine  as  evidence  of  phenol  poisoning. 

Treatment  of  symptoms. 
Convulsions. 

To  lessen  irritability  of  centres,  and  diminish  frequency  and  vio- 
lence of  clonic  convulsions. 
Chloral. 

Dose,  gr.  xv  (1  Gm.)  every  three  hours,  or 

gr.  xxx  (2  Gm.)  every  6  hours, 

increasing  to  gr.  xlv  (3  Gm.)  or 

gr.  Ix  (4  Gm.)  every  six  hours  if  necessary.    (Adult  dose.) 
Bromides.     In  double  dose  of  chloral;  either  potassium  bromide 

alone  or  the  triple  bromides  of  sodium,  potassium  and  ammonium. 

Not  likely  to  be  effectual  alone,  but  well  to  combine  with  chloral. 

Give  in  solution  in  water  through  stomach  or  nasal  tube,  or  by 

rectum  in  a  couple  of  ounces  (60  Gm.)  warm  milk. 
Morphine. 

Lessens  spasms,  relieves  pain,  induces  sleep. 

Indicated  before  any  procedure  likely  to  induce  convulsions,  such 
as  enemas,  rectal  or  nasal  feeding,  catheterizing. 

Indicated  during  a  convulsion. 

Doses,  sulphate,  gr.  1/4  to  gr.  1/3  (0.015-0.020  Gm.)  up  to  gr.  i  or 

gr.  iss.  to  gr.  ii  (0.060-0.10-0.120  Gm.)  a  day. 
Atropine. 

May  be  combined  with  morphine. 
Chloroform. 

Indicated  in  severe  and  painful  convulsions. 
Inhalation. 

Intermittently  at  periods  of  clonic  convulsion. 

Continuous  for  hours  (not  free  from  danger) . 
Magnesium  sulphate. 

(For  intradural  use,  see  text.) 
Other  drugs  that  have  been  recommended. 

Chloretone,  gr.  xxx  (2  Gm.),  every  two  hours  until  sleep  occurs. 

Give  in  whiskey  by  mouth  or  olive  oil  by  rectum. 


TETANUS  727 

Atropine. 

Indicated  as  above  with  morphine  or  alone  to  lessen  spasms,  also 

to  diminish  over-secretion  of  mucus  in  air  passages. 
Dose,  of  the  sulphate,  gr.  1/100  to  gr.  1/25  (0.0006-0.0025  Gm.)  into 

contracted  muscles. 
Repeat  at  four-hour  intervals. 
Watch  for  toxic  symptoms,  widely  dilated  pupils,  great  dryness  of 

mucous  membranes,  rash,  delirium. 
Hyoscine  hydrobromide. 

Has  same  effect  as  atropine,  but  more  depressant  to  cardiac  and 

respiratory  centres. 

Dose,  gr.  1/100  (0.0006  Gm.)  twice  a  day. 
Physostigma. 
Use  physostigmine  sulphate,  gr.  1/6  (0.010  Gm.),  hypodermically 

every  three  to  four  hours. 

Circulation. 

Exhaustion  from  convulsions  may  indicate  use  of  circulatory  stim- 
ulants. 

Use  digitalis  series  for  sustained  effect  and  caffeine  or  camphor  for 
immediate  effect.  (See  Chap.  IX.) 

Prophylaxis. 

Treatment  of  the  wound. 

Cleanse  wound  with  soap,  water,  and  alcohol,  or  paint  with  tinc- 
ture of  iodine. 

Lay  wound  open  to  bottom.    Remove  foreign  particles. 

Cut  away  lacerated  flesh  or 

Excise  wound  area;  then  use 
Antiseptics. 

Three  per  cent,  alcoholic  solution  of  iodine  or  phenol  liquified, 
followed  by  alcohol. 

Pack  loosely  with  gauze  saturated  with  the  iodine  solution. 

Dress  daily,  irrigating  with  peroxide  of  hydrogen. 

Let  wound  granulate  from  the  bottom. 

Powdered  or  liquid  antitoxin  has  been  used  in  the  wound. 

Antitoxin  administration. 
Should  be 'given  at  once. 
Dose,  1,500  units. 

Best  into  muscles  about  the  site  of  the  wound. 
Second  dose  of  same  amount  should  be  given  in  eight  or  ten  days. 
Third  dose  or  repeated  doses  at  these  intervals  until  wound  is  healed 

are  given  by  most  cautious. 

In  a  child  1,000  units  may  answer,  but  1,500  are  better. 
Serum  disease,  as  after  diphtheria  antitoxin,  may  follow. 
It  is  of  small  consequence. 


CHAPTER  XLI 

INFECTIOUS  JAUNDICE   (WEIL'S  DISEASE) 

THERE  is  some  question  as  to  the  propriety  of  using  the  terms  Infectious 
Jaundice  and  WeiPs  Disease  as  synonymous.  Of  late  Infectious  Jaun- 
dice has  been  taken  to  mean  a  definite  infection  attributable  to  a  spiro- 
chete,  the  spirocheta  ictero-hemorrhagiae,  the  clinical  picture  of  which 
is  fairly  clear  cut.  This  same  term  had  been  applied  long  ago  to  a  group 
of  cases  later  described  by  Weil  and  to  which  his  name  is  generally 
attached  in  the  literature.  Weil's  disease  and  Infectious  Jaundice  as 
now  understood  have  in  common  the  distinguishing  features  of  jaundice 
and  hemorrhages,  accompanying  a  toxemia,  but  in  some  minor  details 
vary.  It  means  probably  that  Weil's  Disease  covers  a  heterogeneous 
group  of  conditions  with  which  the  major  manifestations  mentioned  are 
associated.  We  shall  discuss  here  the  spirochetal  infection;  but  the 
measures  mentioned,  with  the  exception  of  specific  therapy,  are  applica- 
ble to  one  and  the  other. 

According  to  the  Japanese  workers,  to  whom  we  owe  so  much  in  the 
investigation  of  this  disease,  the  portal  of  entry  is  by  the  skin,  broken  or 
intact,  or  by  the  gastro-intestinal  tract.  Excretion  occurs  in  the  feces 
and  urine  and  the  organism  is  readily  recovered  from  the  latter,  from 
early  in  the  disease  up  to  5  to  6  weeks,  but  usually  by  the  end  of  the 
second  week.  In  the  body  the  spirochetes  are  distributed  especially 
to  the  kidneys,  the  liver,  the  lymph  nodes  and  spleen.  They  are  found 
in  the  heart  muscle,  too. 

The  most  obvious  lesion  is  curiously  confined  to  the  duodenum,  the 
pyloric  end  of  the  stomach  and  the  upper  portion  of  the  jejunum.  Here 
the  congestion  is  intense  and  the  papilla  of  Vater  involved.  The  ob- 
struction seems  to  be  at  the  papilla,  for  the  gall-ducts,  gall-bladder  and 
liver  are  but  little  affected,  considering  the  intensity  of  the  jaundice. 
It  is  to  be  noted  that  the  toxemia  seems  to  be  due  to  the  sptrochetosis 
rather  than  the  jaundice  and  indeed,  jaundice  may  be  absent. 

The  incubation  period  when  infection  occurs  by  the  skin  is  5  to  7 
days.  It  is  seldom  later  than  two  weeks. 

Symptoms.  The  onset  may  be  sudden  or  gradual  with  the  usual 
symptoms  of  acute  infection,  malaise,  fever,  headaches,  generalized 
pains,  cramps  in  muscles,  prostration,  anorexia,  often  vomiting  and 
pain  in  the  upper  abdomen,  striking  constipation  and  marked  congestion 


INFECTIOUS  JAUNDICE  (WEIL'S  DISEASE)  729 

of  the  conjunctiva.  Herpes  is  common.  The  blood  count  shows  a 
moderate  leucocytosis  and  polynucleosis,  exceptionally  both  are  quite 
high.  The  pulse  is  relatively  slow,  the  blood  pressure  is  normal.  In  the 
early  days  spirochetes  may  be  recovered  from  the  blood  and  the  blood 
shown  to  be  infective  to  inoculated  animals,  but  by  the  fifth  day  this 
infectivity  is  markedly  diminished,  due  probably  to  the  formation  of 
antibodies.  By  the  fifth  day  spirochetes  are  usually  excreted  by  the 
urine.  This  initial  or  febrile  period  lasts  six  to  seven  days.  The  tempera- 
ture in  the  beginning  may  be  102°  F.  to  103°  F.  and  comes  down  by 
lysis  nearly  to  normal.  During  this  period  hemorrhages  are  common, 
occurring  from  the  lungs,  nose,  stomach,  intestine  and  kidneys,  together 
with,  in  some  cases,  purpura,  and  Dawson  and  Hume  note  a  "curious 
purplish  discoloration  in  the  abdomen,  loins  and  lower  part  of  the  chest 
in  those  cases  which  were  most  deeply  jaundiced." 

The  second  or  icteric  stage  begins  at  about  the  end  of  the  first  week. 
Most  commonly  the  jaundice  appears  on  the  fifth  day,  though  it  may 
appear  as  early  as  the  second  day  or  be  delayed  until  near  the  end  of  the 
second  week.  The  degree  of  jaundice  varies.  Bile  appears  in  the  urine 
and  the  stools  are  clay  colored.  During  this  period,  too,  occur  hemor- 
rhages and  marked  general  weakness.  Convulsions  have  occurred  in 
some  fatal  cases  and  the  heart  may  show  some  inefficiency,  though  this 
is  not  characteristic.  It  is  in  this  second  period  that  fatal  issues  com- 
monly occur. 

A  secondary  rise  of  temperature,  after  an  afebrile  period  of  two  to  ten 
days  takes  place  at  the  end  of  the  second  week  in  a  certain  number  of  the 
cases,  30  per  cent,  to  40  per  cent.  This  rise  varies  in  its  duration,  but 
may  last  several  days,  be  quite  irregular,  be  trivial  or  be  quite  as  marked 
as  the  original  fever  or  even  higher. 

The  third  and  last  period  is  that  of  convalescence.  It  begins  with  the 
third  week  unless  delayed  by  the  relapse  or  after  fever,  the  secondary 
rise. 

The  icterus  gradually  fades  and  the  anaemia  and  emaciation  become 
more  pronounced.  Spirochetes  are  no  longer  found  in  the  blood,  but 
may  still  be  recovered  from  the  urine,  especially  in  the  relapsing  cases. 
Indeed,  though  diminishing  after  the  twenty-fifth  day,  they  may  be 
found  in  the  urine  as  late  as  the  40th  day  in  the  average  case  and  even 
later  in  the  exceptional. 

Treatment.    That  of  all  acute  infections.    (See  Chap.  I.) 

The  patient  is  put  to  bed  in  a  well  ventilated  room,  to  which  the 
sun  has  access,  in  a  comfortable  bed.  Daily  sponge  baths  are  given,  the 
mouth  properly  attended  to  and  quiet  and  good  nursing  afforded. 

Diet.    Gastro-intestinal  symptoms  are  fairly  constant  and  some- 


730  TREATMENT  OF  ACUTE  INFECTIOUS  DISEASES 

times  severe.  It  is  useless  to  force  the  diet  while  these  disturbances 
obtain. 

It  is  better  to  respect  the  meaning  of  the  anorexia  and  refrain  from 
giving  food  until  nausea  and  vomiting  cease  and  then  begin  tentatively 
with  milk  (better  skimmed)  or  broths,  such  as  mutton  and  chicken 
(freed  from  fat),  white  of  egg,  thoroughly  cooked  cereals,  toast;  enlarging 
on  the  diet  as  the  patient  demonstrates  his  ability  to  handle  larger 
quantities. 

Water  should  be  given  frequently  in  small  quantities  if  there  is  nausea, 
in  larger  amounts  if  the  stomach  retains  it. 

Specific  Treatment.  The  Japanese  workers  Inada,  Ido,  Hoki,  Ito 
and  Wani  recommend  the  use  of  a  specific  serum. 

As  in  the  use  of  all  specific  sera,  early  administration  constitutes 
a  most  important  factor  in  success. 

Dose.  Sixty  c.c.  should  be  given  in  24  hours,  in  divided  doses  at  5 
to  6  hours'  intervals. 

The  intravenous  route  is  the  best;  next,  the  intramuscular. 

It  was  the  experience  of  the  investigators  quoted  that  the  serum  rarely 
failed  to  cause  a  complete  disappearance  of  spirochetse  from  the  cir- 
culating blood. 

The  mortality  was  reduced  from  30.6  per  cent,  to  17.3  per  cent  in 
their  series. 

Bowels.  When  first  seen  a  saline  may  be  given  of  Epsom  salt  or 
Rochelle  salt  or  if  there  is  nausea  and  vomiting,  divided  doses  of  calomel, 
gr.  1/4  (0.015  Gm.)  every  half-hour  for  five  or  six  doses,  followed  by  the 
salt;  or  a  salt  in  divided  doses  of  3i  (4  Gm.)  every  quarter  hour  for  five 
or  six  doses.  Neither  the  calomel  nor  the  salt  should  be  used  in  drastic 
doses.  Later  enemata  or  mild  salines  every  day  or  every  second  day 
may  be  used. 

Nausea  and  vomiting  may  be  alleviated  by  cracked  ice,  the  appli- 
cation of  mustard  paste  to  the  epigastrium,  stomach  washing  or  the 
use  of  such  drugs  as  bismuth  subnitrate  gr.  xv  to  gr.  xxx  (1-2  Gm.), 
bicarbonate  of  soda  gr.  x  to  gr.  xx  (0.6-1.3  Gm.)  or  oxalate  of  cerium 
gr.  ii  to  gr.  v  (0.15-0.30  Gm.)  or  a  combination;  codeine  sulphate  gr. 
1/8  to  gr.  1/4  (0.008-0.015  Gm.)  or  cocaine  hydrochloride  gr.  1/5  (0.01 
Gm.)  are  indicated  in  more  severe  cases  and  even  morphine  in  the  worst. 

Diarrhea.  Attention  to  the  bowels  as  set  forth  above,  restriction 
of  fat  in  food  and  sufficiency  of  water  to  lessen  the  incidence  and  severity 
of  the  diarrhea. 

Bismuth  subnitrate  in  doses  of  gr.  xxx  (2  Gm.)  every  two  hours  is  the 
best  drug  to  use;  opium  being  reserved  for  the  most  severe  forms. 

Colicky  pains  are  relieved  by  hot  fomentations. 


INFECTIOUS  JAUNDICE  (WEIL'S  DISEASE)  731 

Fever.  Temperature  of  102°  F.  to  103°  F.  are  reached  by  the  second 
or  third  day  and  gradually  decreases  throughout  the  first  week. 

It  but  rarely  requires  treatment  other  than  that  which  contributes 
to  the  patient's  comfort,  afforded  by  sponge  baths. 

Nervous  Symptoms.  Headache,  delirium  or  coma  may  occur. 
For  the  headache  the  ice-coil  is  to  be  recommended,  delirium  may  re- 
quire small  doses  of  morphine. 

Pains  in  the  legs  are  at  times  very  hardly  borne  and  the  applications 
of  hot  stupes  and  mild  analgesics,  such  as  the  salicylates  are  required. 

Jaundice  appears  on  about  the  fifth  day.  This  jaundice  lasts  about 
two  weeks.  There  is  no  treatment  that  probably  affects  the  degree  or 
intensity  of  the  jaundice,  but  the  salicylates  as  being  thought  to  stimu- 
late biliary  output  have  been  much  used,  either  as  salol,  sodium  sali- 
cylate  or  aspirin  in  doses  of  gr.  v  to  gr.  x  (0.3-0.60  Gm.)  every  three  or 
four  hours.  They  have  the  advantage,  too,  of  acting  as  antipyretics  and 
analgesics. 

Nephritis  is  a  complication  that  is  not  uncommon  and  demands  daily 
examination  of  the  urine. 

It  is  to  be  treated  like  acute  nephritis  under  other  circumstances. 
(See  Scarlet  Fever,  Chap.  XVII.) 

Rarer  Complications.  Hemorrhages  from  nose,  lungs,  stomach, 
bowel  into  skin  or  serous  sacks. 

Hemorrhages  should  be  treated  as  under  other  conditions.  (See 
Typhoid  Fever,  Chap.  XIV.) 

The  intoxication  in  infectious  jaundice  is  severe;  often  the  patient 
sustains  much  loss  of  flesh,  and  strength  is  but  slowly  regained. 

Fresh  air  out  of  doors,  a  sufficiency  of  good  food  and,  when  feasible, 
a  change  of  climate  does  more  to  shorten  the  period  of  convalescence 
than  drugs.  If  these  are  used,  such  simple  tonics  as  strychnine  sulphate 
gr.  1/30  (0.002  Gm.)  three  times  a  day  or  tincture  of  mix  vomica  m.  x 
to  xx  (0.60-1.30  Gm.)  three  times  a  day  are  given.  Iron  may  be  used. 

Prophylaxis. 

Active  Immunization.  Ido,  Hoki,  Ito  and  Wani  brought  this  about 
by  three  subcutaneous  injections  of  vaccine  at  five  days'  intervals.  They 
used  such  a  suspension  as  contained  60  to  150  spirochetes  in  a  field,. 
1/12  oil,  immersion,  ocular  3  (Leitz)  under  dark  illumination,  in  0.5  per 
cent,  carbolic  acid.  The  first  injection  consisted  of  0.5  c.c.  of  this  sus- 
pension, the  second  1  c.c.,  the  third,  2  c.c.  Active  immunization  should 
prove  a  potent  prophylactic  measure. 

In  Japan  this  infection  seems  to  be  common  among  miners;  hence, 
draining  of  the  mines  and  disinfection  of  the  ground  with  lime  is  advised. 

The  infection  through  the  gastro-intestinal  canal  can  only  be  avoided 


732         TREATMENT  OF  ACUTE  INFECTIOUS  DISEASES 

by  such  precautions  of  cleanliness  in  handling  food  and  boiling  water  and 
disposing  of  infected  secretions  as  are  detailed,  for  example,  under 
Typhoid  Fever.  (See  Chap.  XIV.)  The  urine  and  stools  should  be 
disinfected  for  at  least  40  days  and  as  much  longer  as  the  presence  of 
spirochetes  in  these  excretions  indicate.  Bloody  sputum  during  the 
attack  is  a  source  of  infection  and  must  be  destroyed. 

In  that  group  of  cases  that  cannot  be  attributed  to  spirochetal  in- 
fection and  may  still  be  classed  under  Weil's  Disease,  the  conclusions 
of  Barker  and  Sladen,  resulting  from  a  series  of  cases  may  be  quoted. 

"The  sequence  of  events  in  our  cases,  it  seems  to  us  probable,  was 
as  follows : 

"1.  Ingestion  of  tainted  meat,  containing  living  paratyphoid  ba- 
cilli; (2)  development  of  gastro-enteritis  due  to  this  microorganism, 
and  (3)  the  appearance  of  a  catarrhal  jaundice  due  to  extension  of  the 
gastro-enteritis  to  the  'biliary  passages/" 


SUMMARY 
(For  general  principles,  see  Chap.  I.) 

Diet. 

Refrain  from  urging  food  until  gastro-intestinal  symptoms  subside 

or  ameliorate;  then 

Milk,  broths,  cereals,  white  of  egg,  toast,  all  tentatively. 
Enlarge  on  diet  gradually. 

Water. 
Give  freely  when  well  borne. 

Specific  treatment 

(See  text.) 

Precautions. 

Destroy  all  secretions. 

(See  Typhoid  Fever,  Chap.  XIV.) 

Bowels. 
Salts,  Epsom  or  Rochelle  5ss.  to  5i  (15-30  Gm.)  in  three-quarters 

glass  of  water. 

If  there  is  nausea  or  vomiting  precede  the  salt  with  calomel  in 
divided  doses,  gr.  1/4  (0.015  Gm.),  every  hour  for  four  to  five  doses. 
Later. 

Mild  salines,  milk  of  magnesia,  citrate  of  magnesia  or  Hunyadi 
water  or  enemata. 


INFECTIOUS  JAUNDICE  (WEIL'S  DISEASE)  733 

Nausea  and  vomiting. 

Cracked  ice. 

Mustard  paste  (1  to  4  or  5  of  flour)  to  epigastrium. 

Lavage. 

Bismuth  subnitrate,  gr.  xv  to  gr.  xxx  (1-2  Gm.). 

Sodium  bicarbonate,  gr.  x  to  gr.  xx  (0.60-1.30  Gm.). 

Cerium  oxalate,  gr.  ii  to  gr.  v  (0.15-0.30  Gm.). 

Combine  the  above.    Give  every  two  or  three  hours  in  water  or  in 
the  milk. 

Codeine  sulphate,  gr.  1/8  to  gr.  1/4  (0.008-0.015  Gm.). 

Cocaine  hydrochloride,  gr.  1/5  (0.01  Gm.). 
Severe  cases. 

Morphine  sulphate,  gr.  1/16  to  gr.  1/8  (0.004-0.008  Gm.). 

Diarrhea. 

Give  water  freely. 

Restrict  fat  in  food  (skim  the  milk) . 
Boil  milk. 

Bismuth  subnitrate,  gr.  xxx  (2  Gm.  every  two  hours). 
Most  severe  cases. 
Powdered  opium,  gr.  ss.  to  gr.  i  (0.03-0.06  Gm.)  every  four  hours. 

Colic. 
Hot  fomentations  to  abdomen. 

Headache. 

Delirium,  coma. 

Ice-coil  or  ice-bag  to  head. 
Severe  cases. 

Morphine  sulphate  (hypodermically),  gr.  1/12  to  gr.  1/4  (0.005- 
0.015  Gm.). 

Pains  in  legs. 
Hot  stupes. 

Salicylate  of  soda,  gr.  v  to  gr.  x  (0.30-0.60  Gm.),  every  two  hours  or 
Aspirin  same  dose  and  interval. 

Complications. 

Nephritis. 

(See  Scarlet  Fever,  Chap.  XVII.) 
Hemorrhages. 

(See  Typhoid  Fever,  Chap.  XIV.) 

Convalescence. 
Often  slow. 
Open  air. 
More  food. 
Change  of  climate,  when  feasible. 


734  TREATMENT  OF  ACUTE  INFECTIOUS  DISEASES 

Tonics. 

Strychnine  sulphate,  gr.  1/30  (0.002  Gm.),  three  times  a  day  or 
Tr.  nucis  vomicae,  m.  x-xx  (0.60-1.30  c.c.),  three  times  a  day. 
Iron. 


three  times  a  day. 

Prophylaxis. 

Active  Immunization. 

Avoid  possibility  of  ingesting  tainted   meat  and  polluted  water. 

(See  text.) 

In  infected  districts  boil  water. 
Precautions  in  handling  food. 
Disinfect  urine  and  stools  for  40  days  or  as  long  as  spirochetes  are 

present. 
Destroy  bloody  sputum. 


CHAPTER  XLII 

YELLOW  FEVER 

THIS  disease,  in  the  elucidation  of  whose  mysteries  American  physi- 
cians have  played  the  leading  role,  like  Malaria,  is  transmitted  by  the 
mosquito;  more  definitely  by  the  female  of  Stegomyia  calopus  (Sedes 
calopus).  She  becomes  infected  during  and  only  during  the  first  three 
days  of  man's  illness  with  yellow  fever  and  herself  passes  through  an 
incubation  period  of  from  ten  to  twelve  days  before  she  can  convey  the 
disease  to  another  man.  After  this  she  may  remain  infective  for  a 
considerable  time;  for  fifty-seven  days  in  one  instance.  Although  the 
details  of  the  mode  of  infection  had  been  marked  out  elaborately  the 
organisms  concerned  had  defied  detection  until  the  careful  investiga- 
tions of  Noguchi  seemed  to  be  rewarded  in  1919.  He  found  in  the  blood 
of  persons  sick  with  yellow  fever  an  organism  that  morphologically 
closely  resembles  the  leptospira  ictero-homorrhagise  of  infectious  jaun- 
dice, but  showing  different  immunological  characteristics.  This  organism 
he  was  able  to  detect  in  fresh  blood  by  the  dark  field  illumination;  he 
obtained  it  in  pure  culture;  by  the  injection  of  blood  and  tissue  of  yellow 
fever  patients,  he  produced  in  animals  a  disease  characteristic  of  yellow 
fever;  he  recovered  it  again  from  the  blood  and  organs  of  these  animals; 
and  it  gave  a  Pfeiffer  phenomenon.  Furthermore  he  was  able  to  trans- 
mit the  disease  from  animal  to  animal. 

Symptoms.  The  onset  is  sudden  with  chilly  sensations,  rise  of 
temperature,  headache  and  backache.  After  some  irregularities  the 
temperature  abates  about  the  third  or  fourth  day  at  which  time  con- 
junctival  icterus  may  be  seen.  After  a  brief  intermission  or  remission 
of  the  temperature  and  diminution  of  evidences  of  intoxication,  a  re- 
newed fever  and  toxemia  with  deepening  jaundice,  gastric  distress, 
vomiting,  even  a  bloody  black  vomit,  delirium  and  coma  ensues. 

Hemorrhages  and  kidney  incompetency  are  often  accompaniments. 
The  pulse  is  characteristically  slow  (Faget's  sign). 

Stitt  states  that  the  blood  pressure  during  the  sthenic  period  is  very 
high,  sometimes  200,  but  begins  to  fall  on  second  day  progressively  until 
in  the  asthenic  period  it  is  very  low,  sometimes  down  to  70. 

Isolation.  We  now  know  definitely  that  there  are  three  links  in  the 
chain  of  transmission,  any  one  of  which,  abolished,  will  prevent  in- 


736  TREATMENT  OF  ACUTE  INFECTIOUS  DISEASES 

fection:  (1)  Sjegomyia  calopus;  (2)  its  access,  to  a  yellow  fever  patient; 
(3)  its  access  later  to  a  well  person. 

The  prevention  of  (2),  then,  by  isolation  becomes  imperative;  more- 
over, during  an  epidemic  all  suspects,  suffering  from  what  may  be 
deemed  early  symptoms  of  the  disease,  should  be  isolated  until  the 
diagnosis  can  be  determined.  White's  instructions  as  given  in  his 
article  in  the  American  Journal  of  Medical  Sciences,  March,  1913,  are 
so  succinct  that  I  will  quote  them  here. 

"In  dealing  with  the  houses  in  which  known  or  suspected  cases  of 
yellow  fever  have  been  discovered,  it  was  my  custom  first  to  see  whether 
the  house  had  been  properly  screened  with  eighteen-mesh  to  the  inch 
wire  cloth,  and  to  have  screening  done  promptly,  using  mosquito  netting 
as  a  substitute  for  wire  cloth,  and  having  the  sick-room  itself,  as  a  double 
precaution,  screened  from  the  remainder  of  the  house.  The  sick-room 
can  be  easily  screened  by  tacking  two  ample  widths  of  the  netting  to  the 
top  and  sides  of  the  door,  arid  attaching  a  wooden  rod  to  the  bottom  of 
each  width,  so  that  the  ends  projecting  in  to  the  door  are  higher  than 
those  at  the  side  resulting  in  the  rod  dropping  into  place  and  pulling  the 
folds  together  immediately  behind  any  one  passing  through. 

"With  Guiteras  I  believe  in  careful  screening  and  in  covering  all 
cracks  around  the  sick-rooms;  also  in  the  quietness  with  which  the  work 
is  done,  to  prevent  disturbing  either  patient  or  mosquito.  The  sick- 
room window  should  be  screened  from  a  ladder  on  the  outside  of  the 
window.  In  order  to  prevent  escape  or  entrance  through  the  chimney 
a  cap  should  be  placed  on  the  top,  or  failing  in  this,  some  loose  paper 
should  be  burned  in  the  fireplace,  with  a  little  petroleum  to  make  a 
rapid  flame,  and  the  front  of  the  fireplace  covered  with  a  screen  of  wire 
netting. 

"After  the  patient  is  in  condition  to  be  removed  to  another  room 
or  house,  three  days  having  elapsed  since  he  became  ill,  he  is  removed 
and  every  crack  pasted  over  into  which  an  insect  may  hide,  and  all 
drawers  opened,  so  that  the  fumigant  used  may  reach  all  places  in  the 
room,  care  being  taken  that  no  mosquitoes  are  shut  between  the  outside 
screen  and  the  window  in  closing  it.  The  room  and  its  contents  are 
subjected  to  either  sulphur  dioxide  or  cyanide,  burning  pyrethrum 
powder  or  any  other  fumigant.  The  whole  house  is  simultaneously 
treated  in  the  same  fashion  if  the  patient  can  be  removed  to  another 
house;  otherwise  we  must  treat  part  at  a  time  with  more  than  usual  care." 

It  is  seen,  then,  that  after  three  or  four  days  the  patient  is  no  longer 
a  source  of  infection,  but  that  he  is  still  to  be  protected  against  further 
infection  by  infected  mosquitoes. 

His  room  should  be  one  to  which  air  has  the  freest  access  and  these 


YELLOW  FEVER  737 

patients  do  very  well  under  a  tent  in  the  open  air.  The  room  should  be 
darkened. 

The  room,  of  course,  is  to  be  screened  until  such  time  as  the  patient 
may  be  removed  from  the  room  in  which  he  was  taken  ill;  that  is,  at 
the  end  of  the  first  three  days  of  his  illness,  during  which  his  blood 
contains  the  virus. 

If  his  condition  warrants,  he  is  then  removed,  and  the  room  is  fumi- 
gated to  destroy  the  mosquitoes.  Doctor  and  nurses  should  protect  parts 
of  the  body  liable  to  be  bitten  and  more  especially  toward  nightfall. 

The  choice  of  the  bed  and  the  care  of  the  bed  observe  the  same  rules 
as  in  other  acute  infectious  fevers.  (See  Typhoid  Fever,  Chap.  XIV.) 

The  certain  knowledge  of  the  only  mode  of  conveyance  of  the  dis- 
ease, i.  e.,  by  the  mosquito,  makes  the  elaborate  use  of  antiseptics,  as, 
for  instance,  in  typhoid  unnecessary. 

Rest.  There  are  abundant  theoretical  reasons  and  such  as  appeal 
to  common  sense,  as  set  forth  in  the  chapter  on  Treatment  of  Acute 
Infectious  Diseases  (see  Chap.  I),  that  should  urge  getting  a  patient 
to  bed  on  the  first  suspicion  of  infection,  beside  the  conviction  of  those 
experienced  in  the  treatment  of  this  disease  that  cases  put  to  bed  early 
are  less  severe  and  less  likely  to  be  fatal. 

Isolation  makes  rest  more  easily  attained  than  when  friends  and 
visitors  have  free  access  to  the  patients.  Bed  pans  are  to  be  used  and 
in  feeding,  the  glass  tube  or  feeding  cup. 

Diet.  Gastric  irritation  is  a  characteristic  of  the  disease  and  makes 
the  matter  of  feeding  a  difficult  one.  All  writers  advise  against  adminis- 
tering food  during  the  first  period  of  three  or  four  days,  while  the  gastric 
disturbance  continues  or  the  fever  remains  up;  even  in  the  second  period 
if  above  102°  F. 

After  four  or  five  days'  abstention  from  food  the  weakness  of  the 
patient  may  urge  upon  us  the  necessity  of  affording  nourishment  in  some 
form  and  recourse  may  be  had  to  rectal  feeding.  In  severe  cases  this  is 
almost  impossible  and  in  any  case  great  care  must  be  taken  not  to 
aggravate  the  irritability  of  the  colon  and  rectum. 

Agramonte  advises  feeding  in  this  manner  on  alternate  days,  and 
suggests  as  a  food  formula: 

Milk 3  ounces  (better  peptonized) 

Whiskey ^  ounce 

Normal  salt  solution 3  ounces 

When  conditions  as  above  enumerated  would  seem  to  permit  of 
it  food  may  be  begun  with  caution  by  the  mouth,  commencing  with 
much  diluted  milk,  with  barley  water,  ice-cream  or  gelatine  jellies. 


738  TREATMENT  OF  ACUTE  INFECTIOUS  DISEASES 

Drinks.  It  is  very  desirable  to  administer  fluids,  if  the  stomach 
will  entertain  them.  Alkaline  waters  seem  the  best  borne. 

Carroll  advises  Vichy  or  other  mineral  water,  to  which  is  added 
sodium  bicarbonate  grains  xxx  (2  Gm.)  to  the  pint  (500  c.c.),  while 
Anderson  is  enthusiastic  over  his  effervescent  mixture  of  potassium 
bicarbonate  grains  xxx  (2  Gm.)  to  a  dessert-spoonful  of  freshly  expressed 
and  strained  lime  juice  given  effervescing  in  Vichy  every  two  hours. 
Mild  lemonade  may  also  be  administered. 

All  food  and  drinks  should  be  ice-cold. 

Bowels.  A  saline  3iv-vi  (15-24  Gm.)  of  Epsom  or  Glauber's  salt, 
best  in  5i  (4  Gm.)  doses  at  frequent  intervals,  should  be  given.  This 
may  be  preceded  by  calomel  grams  iii  to  gr.  v  (0.20-0.35  Gm.)  or  this 
may  be  divided.  If  not  effectual  a  plain  enema  should  follow.  Cathar- 
tics are  only  indicated  at  the  beginning  of  the  disease. 

Care  of  the  Body  and  Mouth.  The  same  rules  are  to  be  followed 
as  after  any  severe  acute  infection.  (See  Typhoid  Fever,  Chap.  XIV.) 

Specific  Treatment.  At  the  time  of  writing,  the  experimental  work 
of  Noguchi  holds  out  some  promise  of  our  ultimately  acquiring  an  im- 
mune serum  of  value. 

Treatment  of  Symptoms.  The  onset,  as  has  been  stated,  is  sudden 
and  severe  and  accompanied  by  headache  and  backache,  often  intense. 

Headache.  It  is  altogether  better  to  avoid  drugs,  since  the  depressant 
effects  of  the  coal  tars  and  the  other  pharmacological  actions  of  the 
morphine  series  are  undesirable,  and  to  rely  upon  cold  applied  to 
the  head  in  the  shape  of  cold  compresses  or  the  ice-bag  or  the 
cold  coil. 

Experienced  clinicians  advocate  the  application  of  heat  to  the  trunk 
and  extremities  at  the  same  time,  as  a  hot  pack,  a  hot  mustard  foot- 
bath or  heat  otherwise  applied  to  the  feet  (see  Pneumonia,  Chap.  IV), 
and  hot  drinks  such  as  lemonade  if  the  stomach  will  stand  it.  They 
believe  that  not  only  is  the  headache  bettered,  but  the  nausea  relieved 
and  the  congestion  of  the  kidneys  lessened. 

Backache.  The  hot  pack,  hot  stupes,  mustard  pastes  or  plasters 
and  rubbing  afford  relief. 

Gastric  Distress.  Pain,  nausea  and  vomiting  are  early  manifesta- 
tions often  persistent  and  later  in  many  instances  giving  rise  to  the 
characteristic  and  ominous  black  vomit. 

No  food  should  be  given  while  the  stomach  is  so  irritable;  a  counter- 
irritant,  mustard  paste  or  mustard  leaf,  may  be  applied  to  the  epigas- 
trium or  the  application  of  the  ice-bag  to  the  same  site  may  be  tried. 

Cracked  ice  is  sometimes  efficacious  or  ice-cold  drinks  in  small  quan- 
tities frequently,  such  as  the  alkalinized  Vichy  water  described  above 


YELLOW  FEVER  739 

and  effervescing  drinks,  as  champagne  or  ginger  ale  in  tea-and  table- 
spoonful  doses. 

If  the  violent  vomiting  still  persists  one  must  have  recourse  to  mor- 
phine in  doses  of  grains  1/4  (0.015  Gm.)  hypodermically. 

If  tenderness  is  severe  or  hiccoughing  occurs,  Carter  highly  recom- 
mends cocaine  hydrochloride,  which  he  gives  in  doses  of  one-half  a  grain 
to  a  grain  in  a  capsule  to  be  taken  with  a  minimum  amount  of  water 
as  a  preventative  of  the  black  vomit.  He  finds  morphine  sulphate  gr. 
1/16-1/12  (0.004-0.005  Gm.)  an  useful  adjuvant  if  the  kidneys  do  not 
contraindicate  the  use  of  it. 

Black  Vomit.  Among  the  measures  recommended  to  relieve  the 
serious  condition  are  the  hemostatics,  such  as  adrenalin  by  mouth 
for  its  constricting  effect  on  the  small  arteries.  Tincture  of  ferric 
chloride  in  doses  of  minims  5  (0.35  c.c.)  every  two  hours  for  the  styptic 
effect  on  the  bleeding  orifices  may  be  given  in  limejuice  and  glycerin; 
calcium  chloride  (Guiteras)  for  its  effect  on  the  coagulation  of  the  blood 
and  oil  of  turpentine  in  doses  of  minims  x  (0.65  c.c.)  for  the  same  pur- 
pose. 

If  there  is  much  pain  in  the  stomach,  Carter  recommends  cocaine  as 
given  above  with  or  without  morphine. 

Fever.  The  period  of  fever  is  short-lived  and  rarely  excessive  and 
demands  no  measures  except  those  designed  for  the  comfort  of  the 
patient,  as  sponging  with  hike-warm  or  cool  water. 

If  the  pyrexia,  however,  attains  high  figures  or  for  any  time  persists 
above  103°  F.,  the  sponges  should  be  given  with  colder  water  from  70° 
F.,  down  to  60°  F.,  or  50°  F.,  depending  on  the  reaction,  at  four-hour 
intervals.  Such  cold  sponging  should  have  a  favorable  effect  on  the 
circulation  and  on  other  structures  burdened  by  the  toxins. 

Urine.  Great  danger  attends  the  not  uncommon  involvement  of 
the  kidneys  and  the  suppression  resulting.  Examinations  of  the  urine 
should  be  made  daily  and  estimates  of  intake  and  output  of  water 
noted.  The  capacity  of  the  kidney  for  secretion  of  water  is  more  im- 
portant than  the  amount  of  albumin  in  the  urine.  Administration  of  a 
sufficiency  of  water  is  important,  but  on  account  of  the  gastric  irritability 
difficult  of  accomplishment.  For  this  reason  saline  rectal  injections  are 
of  value  given  in  amounts  of  10  to  16  ounces  at  four-hour  intervals,  or  the 
Murphy  drip  may  be  tried,  but  care  must  be  exercised  not  to  aggravate 
the  irritability  of  the  intestine  from  which  hemorrhages  are  so  likely  to 
occur.  At  the  same  time  hot  fomentations  should  be  applied  to 
the  lumbar  region  or  the  area  cupped  in  an  effort  to  relieve  the 
congestion. 

Circulation.    The  condition  of  the  heart  and  of  the  principal  vessels 


740  TREATMENT  OF  ACUTE  INFECTIOUS  DISEASES 

should  be  determined  by  frequent  examinations  and  blood-pressure 
readings. 

Depression  of  the  circulation  should  be  met  in  the  same  way  as  in 
other  acute  infections.  (See  Treatment  of  Acute  Infectious  Diseases, 
Chap.  I,  and  Pneumonia,  Chap.  IX.) 

Convalescence.  The  period  depends  on  the  degree  of  intoxication 
throughout  the  illness.  In  the  usual  case  it  is  relatively  short,  so  that 
after  the  fever  has  subsided  for  several  days  the  patient  may  be  allowed 
to  sit  up.  The  patient  gets  back  onto  solid  food  gradually,  the  condition 
of  the  stomach  and  kidneys  affording  the  criteria  for  enlarging  the  diet. 
The  kidneys  are  rapidly  restored  to  normal  condition. 

Prophylaxis.  Three  lines  of  endeavor  to  prevent  infection  are 
to  be  pursued. 

(1)  Destruction  of  mosquitoes  and  elimination  of  their  breeding  places. 

(2)  Isolation  of  the  infected  individual. 

(3)  Precautions  against  bite  of  stegomyia  by  non-immunes. 

To  effect  (1),  the  destruction  of  the  mosquitoes  and  the  elimina- 
tion of  their  breeding  place^,  the  following  measures  are  undertaken: 
First,  as  described  under  the  section  on  isolation,  by  carefully  screen- 
ing the  room  from  the  first  and  by  removal  of  the  patient  after  three 
days  of  illness  with  care  not  to  disturb  the  mosquitoes,  followed  by 
fumigation  of  the  tightly  sealed  room. 

White  calls  the  stegomyia  calopus  a  domestic  mosquito;  that  is,  that 
it  clings  closely  to  the  habitat  of  man  and  breeds  in  water  collected  in 
artificial  receptacles,  cisterns,  barrels,  tubs,  cans,  broken  crockery,  pools, 
vases,  fountains,  drains,  roof  gutters,  in  fact  in  any  stagnant  water 
commonly  to  be  found  about  a  dwelling. 

Of  course,  all  useless  litter  should  be  destroyed  or  disposed  of;  cisterns, 
drains,  etc.,  properly  screened  with  wire  netting  or  constantly  covered 
with  a  film  of  petroleum,  while  small  fish  devour  the  breeding  mosquitoes 
in  fish  ponds  and  fountains.  Swamps,  ponds  or  stagnant  waters  about 
the  locality  infected  must  be  drained,  filled  in  or  treated  with  petroleum. 

(2)  The  isolation  of  the  infected  individual  to  prevent  his  being 
a  source  of  infection  to  others  through  mosquitoes  first  biting  him  has 
been  dealt  with. 

(3)  Precautions  against  bites  of  stegomyia  by  non-immunes  are  first 
a  knowledge  of  the  habits  of  stegomyia  calopus  and  second,  personal 
protection. 

Carroll  says  the  stegomyia  is  a  twilight  mosquito,  feeding  in  early 
morning  and  from  mid-afternoon  until  late  evening  (3  P.  M.-10  P.  M.), 
and  that  in  well-lighted  places  between  9  A.  M.  and  3  P.  M.  there  is  little 
danger  to  non-immunes  even  in  infected  localities. 


YELLOW  FEVER  741 

When  in  an  infected  locality  non-immunes  should  take  care  to  pro- 
tect themselves  against  the  bite  of  stegomyia  and  that  especially  at 
dusk  and  after  dark  by  wearing  mosquito  head-nets,  heavy  gloves  and 
leggings,  choosing  for  a  sleeping  room  as  high  a  room  in  the  house  as 
possible,  being  assured  on  retiring  that  the  room  is  free  from  mosquitoes, 
best  by  fumigating  it,  sleeping  in  a  screened  room  and  in  a  screened  bed. 

They  should  not  expose  themselves  to  the  environment  of  an  infected 
individual  unless  duty  calls  and  then  should  take  such  precautions  as  are 
observed  by  doctors  or  nurses  in  attendance. 

SUMMARY 

Isolation. 

Of  both  patients  and  suspects. 

(For  the  technique  of  isolation,  see  text.) 

Doctor  and  nurse. 

Must  protect  themselves  against  the  bite  of  mosquitoes  and  more 
especially  toward  nightfall. 

Bed. 

(See  Typhoid  Fever,  Chap.  XIV.) 

Diet. 

Gastric  irritation  makes  the  problem  a  special  one.    (See  text.) 
Drinks. 

Alkaline  waters. 
Vichy  or  other  mineral  water  with  sodium  bicarbonate  gr.  xxx 

(2  Gm.)  to  the  pint  (500  c.c.)  (Carroll). 
Potassium  bicarbonate  gr.  xxx  (2  Gm.)  in  a  dessert  spoonful  (3ii  or 

8  c.c.)  freshly  expressed  and  strained  limejuice  given  effervescing 

in  Vichy,  every  two  hours  (Anderson). 
Mild  lemonade. 
All  drinks  ice-cold. 

Bowels. 

Epsom,  Rochelle  or  Glauber's  salt,  3iv-vi  (15-25  Gm.),  best  in  doses 

of  3i  (4  Gm.)  at  frequent  intervals. 
May  precede  by  calomel  gr.  iii  to  gr.  v  (0.20-0.35  Gm.)  in  one  or 

divided  doses. 

Care  of  body  and  mouth. 

(See  Typhoid  Fever,  Chap.  XIV.) 

Treatment  of  symptoms. 
Headache. 
Cold  to  head. 
Ice-bag. 


742  TREATMENT  OF  ACUTE  INFECTIOUS  DISEASES 

Heat  to  extremities. 

Hot  pact. 

Hot  mustard  foot-bath.     (For  technique,  see  Pneumonia.  Chap. 
IX.) 

Hot  drinks;  e.  g.,  lemonade. 
Backache. 

Hot  pack. 

Hot  stupes. 

Mustard  paste  or  plasters. 
Gastric  distress. 

No  food  by  stomach. 

Mustard  paste  or  plaster  to  epigastrium. 

Ice-bag  to  epigastrium. 

Cracked  ice  to  suck. 

Ice-cold  drinks  in  small  quantities. 

Alkaline  Vichy.    (See  above.) 

Effervescing  drinks. 

Champagne,  1  Jn  teaspoonful  or  tablespoonful  doses. 
Lunger  aie,    j 
If  pain  in  stomach  severe  and  black  vomit  threatens  give 

cocaine  hydrochloride,  gr.  ss-1  (0.03-0.06  Gm.)  in  capsule. 
Morphine  sulphate,  gr.  1/16-1/12  (0.004-0.005  Gm.)  may  be 

used  as  an  adjuvant  to  cocaine. 

If  vomiting  is  severe  morphine  sulphate  hypodermically,  gr. 
1/4  (0.015  Gm.). 

Black  vomit. 

Adrenalin  (epinephrin),  1 :1,000  in  doses  of  m.  i  to  m.  xv  (0.060^1  c.c.). 
Tincture  of  the  chloride  of  iron  m.  v   (0.30  c.c.)  in  limejuice  and 

glycerin. 

Calcium  chloride  (Guiteras)  gr.  x  to  gr.  xv  (0.60-1  Gm.). 
Oil  of  turpentine  m.  x  (0.60  c.c.). 
If  black  vomit  threatens  give  cocaine  hydrochloride,  gr.  is-1  (0.03- 

0.06  Gm.)  in  capsule. 
Morphine  sulphate,  gr.  1/16-1/12  (0.004-0.005  Gm.)  may  be  used  as 

an  adjuvant  to  cocaine. 

Fever. 

Needs  consideration  only  when  high  or  very  sustained. 
Cold  sponges. 

Kidneys. 

Congestion. 

Hot  fomentations  over  lumbar  region. 

Circulation. 

As  in  other  acute  infectious  diseases. 

(See  summary  under  Pneumonia,  Chap.  IX.) 


YELLOW  FEVER  743 

Convalescence. 

Usually  short. 

Up  after  temperature  is  normal  a  few  days. 

Increase  diet  as  condition  of  stomach  and  kidneys  warrant. 

Prophylaxis. 

1.  Destruction  of  mosquitoes. 

(See  Malaria,  Chap.  XV.) 

2.  Isolation  of  the  infected  individual. 

(See  text  under  isolation.) 

3.  Protection  of  non-immunes  against  bite  of  stegomyia. 

Noting  the  feeding  time,  in  morning  until  about  9  o'clock, 

and  evening  after  3  o'clock. 

Wear  mosquito  head  nets,  heavy  gloves  and  leggings. 
Choose  as  sleeping  room  one  high  up. 
Sleep  in  screened  room  and  screened  bed. 
It  is  well  to  fumigate  the  room  before  retiring. 
Avoid  exposure  to  environment  of  infected  individuals. 


CHAPTER  XLIII 

RAT-BITE  FEVER 

THIS  disease,  so  recently  called  to  our  attention  in  this  country,  I 
am  convinced  from  my  own  experience  with  it,  is  not  so  rare  that  any 
practitioner  can  afford  to  disregard  it. 

It  is  caused  as  the  name  denotes,  by  the  bite  of  a  rat  (or  rarely  of  a 
cat,  weasel  or  other  animal) ,  by  which  the  sufferer  is  inoculated  with  a 
spirochete,  spirocheta  morsus  muris. 

In  due  time  a  symptom  complex  appears,  offering  two  characteristic 
features,  a  relapsing  type  of  fever  and  an  eruption. 

Repeated  febrile  attacks  of  4  to  5  days,  separated  by  afebrile  intervals 
of  a  few  days,  more  especially  when  these  attacks  are  accompanied  by 
an  eruption  should  always  lead  us  to  enquire  for  a  rat-bite  or  seek  local 
evidences  of  it.  This  disease  has  long  been  appreciated  in  Japan,  but 
has  only  recently  elicited  our  attention  in  this  country. 

Not  all  rats  are  infected  nor  are  all  bites  of  infected  animals  necessarily 
the  source  of  infection,  for  bites  through  clothing  may  be  robbed  of  their 
virus  or  abundant  bleeding  free  the  wound;  bites  on  exposed  parts  then 
are  more  likely  to  be  infected.  There  is  a  curious  similarity  to  rabies  in 
these  particulars.  There  has  been  no  unanimity  among  investigators  as 
to  the  causative  agent;  it  having  been  ascribed  to  diplococci,  spirilla, 
spirochetae  and  streptothrix.  Many  competent  men  name  the  organism 
a  streptothrix  muris  ratti,  but  perhaps  the  strongest  argument  is  put  up 
for  the  spirocheta  morsus  muris. 

The  spirochete  is  to  be  found  in  the  blood,  in  the  exanthem  and  the 
lymph  glands,  especially  at  the  height  of  the  fever  during  the  first  few 
recurrences. 

Incubation.  Arkin  gives  the  average  as  12  days  and  in  some  in- 
stances as  short  as  five  days.  Other  writers  fix  it  at  a  much  longer 
period,  6  to  8  weeks  or  even  months;  thus  affording  much  the  same 
discrepancies  as  is  the  case  in  rabies. 

Symptomatology.  The  rat-bite  may  or  may  not  have  healed  during 
the  incubation  period,  but  with  the  onset  of  active  manifestations  the 
patient  experiences  a  burning  and  pain  at  the  site  of  the  lesion  and  a 
redness  with  a  bluish  tint  and  some  induration  develops  here,  surrounded 
by  some  edema.  Arkin  likens  its  appearance  to  extra-genital  primary 


RAT-BITE  FEVER  745 

lesion  in  syphilis,  sometimes  the  lesion  vesiculates.  From  this  inflamed 
lesion  the  lymphatics  become  involved  and  show  streaks  of  red;  this 
spreads  to  the  regional  glands,  which  become  large  and  tender.  Some 
malaise  is  experienced,  then  the  patient  suffers  a  chill,  followed  by  an 
abrupt  rise  of  temperature  to  102°  F.  to  105°  F.,  accompanied  by  head- 
ache and  pains  and  aches,  nausea  and  vomiting  and  in  severe  cases  with 
mental  disturbances,  delirium  and  coma.  The  febrile  period  lasts  three 
to  six  days  and  then  falls  by  crisis  with  profuse  sweating.  During  the 
attack  the  eruption  appears,  though  in  some  instances  it  is  delayed  to 
the  second  or  third  or  later  relapses.  It  is  a  reddish-blue  macular 
eruption,  later  becoming  a  little  elevated,  varying  greatly  in  size  from 
1/3  inch  to  huge  blotches  and  paler  in  the  centre  than  at  the  periphery. 
I  mistook  this  eruption  in  one  case  for  an  erythema  multiforme.  It 
may  be  confined  to  the  area  about  the  bite  or  to  a  limited  area,  but  as  a 
rule  is  more  widely  distributed,  appearing  on  face,  limbs  and  extremities, 
even  on  the  palms  and  soles  and  in  rare  instances  in  the  mouth.  The 
nervous  system  is  often  much  disturbed.  After  the  febrile  attack  comes 
an  afebrile  period  of  2  to  6  days  when  the  fever  recurs  with  a  fresh  out- 
burst of  the  exanthem,  and  so  these  febrile  and  afebrije  periods  continue, 
the  chart  taking  on  a  characteristic  appearance  that  should  suggest  the 
infection  at  once.  These  grow  less  in  severity  and  usuafly  last  about 
two  months  but  have  been  known  to  continue  for  years  with  long 
afebrile  periods  even  for  months  intervening.  In  severe  cases  each 
attack  is  worse  until  a  fatal  issue  may  occur. 

The  blood  picture  is  not  constant.  Usually  there  is  a  moderate 
leucocytosis  from  13,000  to  20,000,  dropping  during  the  afebrile  period. 
Sometimes  there  is  a  marked  increase  in  mononuclears,  sometimes  in 
polymorphonuclears  and  in  some  cases  a  moderate  increase  in  eosino- 
philes.  The  diagnosis  is  clinched  by  finding  the  organism  in  the  blood, 
at  the  site  of  the  rat-bite,  in  the  exanthem  and  in  the  lymphatic  glands. 
The  organism  stains  readily  with  Giemsa's  stain,  LoefHer's  methylene 
blue  and  gentian  violet  and  by  other  methods  such  as  the  India  ink 
and  Levaditi's.  It  shows  the  spirochetal  curves  of  varying  numbers,  is 
short  and  thick  in  the  blood  and  longer  in  the  tissue  and  is  flagellated, 
having  a  rapid  movement  in  the  blood.  By  inoculation  of  mouse  or 
guinea-pig  they  may  be  demonstrated  in  five  to  fourteen  days. 

Treatment.  The  course  of  the  disease  is  long  continued,  the  fever 
often  deviates  from  the  type  as  given  above,  in  some  cases  being  con- 
tinuous. The  nervous  symptoms  may  be  the  essential  feature  in  the 
disease  and  the  exhaustion  be  absent.  These  cases  may  be  very  acute 
with  continued  or  remittent  fever  or  the  fever  may  be  absent.  In  mild 
cases  during  the  afebrile  periods  the  patients  are  relatively  comfortable 


746  TREATMENT  OF  ACUTE  INFECTIOUS  DISEASES 

and  out  of  bed.  In  the  more  severe  forasmuch  careful  nursing  and 
medical  consideration  is  needed. 

The  selection  of  the  room,  its  ventilation,  the  choice  and  preparation 
of  the  bed,  the  care  of  the  body,  the  mouth  and  the  nose  are  such  as 
should  be  exercised  in  any  acute  infection  and  are  to  be  found  under 
Typhoid  Fever,  Chap.  XIV. 

Diet.  On  account  of  the  long  infection  the  diet  should  be  abundant, 
affording  3,000  calories,  or  more  if  the  patient  desires  it;  the  choice  of  the 
food  depending  on  the  presence  or  absence  of  fever  or  its  degree.  One 
will  find  suggestions  in  the  dietary  given  under  typhoid  fever.  Except 
at  the  onset  of  the  paroxysms  there  is  but  little  gastro-intestinal  dis- 
turbance. Water  should  be  administered  freely.  Often  there  is  con- 
siderable thirst  during  the  febrile  periods.  Fruit-juices,  lemonade, 
orangeade  and  alkaline  waters  may  be  and  should  be  offered  freely. 

Bowels.  At  the  beginning  of  the  attack  a  cathartic  may  be  given 
of  castor  oil  5ss.-i  (15-30  c.c.)  or  salts;  Epsom,  Rochelle  or  Glauber's 
salt,  3ss.-i  (15-30  Gm.)  which  may  or  may  not  be  preceded  by  calomel 
gr.  i  ss.-ii  (0.10-0.120  Gm.)  which  is  often  better  borne  and  even  more 
effectual  when  given  in  divided  doses  of  gr.  1/4  (0.015  Gm.)  at  quarter- 
hour  intervals.  Such  divided  doses  are  better  borne  in  nausea,  and 
indeed,  are  credited  with  antiemetic  properties.  Enemata  or  mild 
cathartics  may  be  relied  on  during  the  later  stages. 

Pains  and  Aches  which  are  quite  striking  in  the  febrile  periods  and 
particularly  in  the  lower  extremities  as  well  as  headache,  hemicrania, 
neuralgic  pains  and  pain  in  the  bitten  part  may  be  relieved  by  acetyl- 
salicylic  acid  (aspirin)  in  doses  of  gr.  x  (0.66  Gm.)  at  2  or  3  hour  inter- 
vals or  by  the  use  of  the  coal  tars.  Of  these  latter  acetphenetidin 
(phenacetin)  and  acetanilid  are  in  most  common  use.  The  dose  of 
phenacetin  for  these  purposes  is  gr.  iii  to  gr.  v  (0.20  to  0.30  Gm.)  at  2  or 
3  hour  intervals;  acetanilid  gr.  ii  to  gr.  iii  (0.012  to  0.20  Gm.)  at  the  same 
intervals.  I  think  excellent  results  are  to  be  obtained  by  small  doses, 
for  example,  gr.  iss.  of  acetanilid  at  intervals  of  1/2  to  1  hour  for  six 
doses,  then  at  2  hour  intervals.  No  coal  tar  should  be  used  over  a 
considerable  period  of  time  and  only  in  sthenic  cases,  never  when  the 
circulation  is  imperilled.  It  is  well  to  combine  them  with  equal  or  double 
the  amount  of  bicarbonate  of  soda  which  lessens  the  irritating  and 
toxic  effects  and  with  caffeine,  citrated,  in  small  doses  to  increase  the 
anodyne  effect.  This  should  be  omitted  if  there  is  insomnia.  If  results 
are  not  obtained  in  a  half  a  dozen  doses  of  the  above,  one  should  have 
recourse  to  more  potent  drugs,  such  as  codeine  phosphate  in  doses  of 
gr.  1/8  to  gr.  1/2  (0.008  to  0.030  Gm.)  by  mouth  or  with  more  certain 
effect  by  the  subcutaneous  route.  In  very  severe  cases  morphine  may 


RAT-BITE  FEVER  747 

be  used  hypodermatically,  but  sparingly  and  in  the  least  doses  that  are 
effectual,  beginning  with  gr.  1/12  (0.005  Gm.)  of  the  sulphate. 

Sleeplessness.  As  the  disease  is  long  continued  and  the  demand  for 
hypnotics  may  be  considerable  it  is  well  to  begin  with  the  milder 
bromides  gr.  xv-gr.  xxx  (1  to  2  Gm.),  trional  gr.  v  to  xv  (0.33  to  1  Gm.), 
chloralamid  gr.  xx-xxx  (1.33  to  2  Gm.),  adalin  gr.  v  (0.33  Gm.),  barbital 
(veronal)  or  sodium  barbital  (medinal)  gr.  v-viiss.  (0.33-0.50  Gm.). 
changing  from  time  to  time,  remembering  that  often  the  effects  carry- 
over to  the  second  night.  Give  early  in  the  morning.  If  insomnia  is 
due  to  pain,  codeine  and  morphine  may  by  used  in  doses  given 
above. 

For  Delirium.  Use  morphine  gr.  1/4  (0.015  Gm.)  or  hyoscine 
hydrobromide  gr.  1/200  (0.0003  Gm.).  • 

Extreme  nervousness,  paraesthesia  and  hyperesthesia  call  for  small 
doses  of  bromides  gr.  x  to  gr.  xv  (0.66-1  Gm.)  or  trional  in  gr.  ii  (0.120 
Gm.)  doses  every  two  hours  during  the  day  or  luminal  in  1/2  grain  doses 
(0.030  Gm.),  three  times  a  day. 

Dizziness — ringing  in  the  ears,  blurring  of  vision  are  occasionally 
symptoms  for  which,  if  the  source  of  anxiety  and  restlessness,  bromides 
may  be  administered. 

Fever.  Antipyretics  should  not  be  used,  but  cool  sponging  afford 
comfort  and  in  the  higher  degrees  of  fever  slush  baths  (see  Typhoid 
Fever)  or  cold  packs  (see  Chap.  XVII)  may  be  tried. 

Skin.  This  requires  only  cleanliness  and  the  application  of  drying 
powders. 

Circulation.  Failure  of  the  circulation  is  to  be  met  by  vigorous 
digitalis  medication.  (For  details  and  the  treatment  of  collapse,  see 
Pneumonia,  Chap.  IX.) 

The  inflamed  and  swollen  glands  may  be  painful.  Local  applications 
of  heat,  as  fomentations,  or  cold  as  an  ice-bag  or  25  per  cent,  ointment 
of  icthyol  may  be  utilized. 

The  glands  do  not  suppurate. 

Specific  Treatment.  There  is  none  that  is  worthy  of  the  name,  but 
as  the  causative  agent  is  a  spirochete,  arsenic  combinations  are  indicated. 
Arsphenamine  (salvarsan)  or  the  neo-arsphenamine  has  been  used  with 
very  excellent  results  in  many  cases.  I  think  it  should  be  used  in  every 
case.  The  mode  of  administration  is  as  in  syphilis,  intravenously,  and 
in  the  same  dosage,  0.40  Gm.  in  females  and  0.60  Gm.  in  males,  of  the 
arsphenamine;  0.10  Gm.  to  each  thirty  pound  body  weight  and  0.75  Gm. 
in  females  and  1  Gm.  to  males. 

The  effects  seem  to  be  the  same  whether  given  at  the  height  of  the 
fever  or  during  the  periods  of  apyrexia.  Some  cases  are  cured  after  a 


748  TREATMENT  OF  ACUTE  INFECTIOUS  DISEASES 

single  dose;  others  require  more.  When  the  drug  is  effectual  the  relief  of 
symptoms  is  immediate. 

While  the  reported  results  are  very  gratifying,  I  have  seen  a'fatal  issue 
after  repeated  salvarsan  injection  in  adequate  dosage. 

Mercury  has  also  been  recommended.  If  used  one  should  follow  the 
usual  routine  in  syphilis,  especially  the  hypodermic  route. 

Complications.  Nephritis  occasionally  occurs  and  then  is  to  be 
treated  as  under  other  circumstances.  (See  Scarlet  Fever.)  Ulcerative 
myocarditis  has  been  reported  and  attributed  to  complicating  strep- 
tothrix  infection. 

The  disease  is  often  long  and  exhausting.  Throughout  a  long  course 
the  condition  of  the  blood  should  be  studied  and  iron  given  for  anaemia. 
My  preference  is  Vallet's  mass  (Massa  ferri  carbonatis)  in  gr.  x  (0.66 
Gm.)  doses,  three  times  a  day  or  arsenic  may  be  added,  as  arsenious 
acid  gr.  1/40-gr.  1/20  (0.0015  to  0.003  Gm.)  or  one  may  use  sodium 
cacodylate  hypodermically  in  gr.  ss.  to  gr.  i  (0.030  to  0.060  Gm.)  doses. 

Green  citrate  of  iron  hypodermically  may  also  be  tried  in  doses  of  gr. 
3/4  (0.05  Gm.). 

Convalescence.  Fresh  air,  sunlight,  an  abundance  of  food,  change 
of  climate,  if  it  can  be  brought  about,  and  treatment  of  the  anaemia  are 
the  indications. 

Prophylaxis.  Cauterization  with  fuming  nitric  acid,  thoroughly, 
even  if  incision  has  to  be  made  for  it,  is  advisable. 


SUMMARY 

Treatment. 

Room,  bed,  care  of  the  body,  mouth  and  nose. 
(See  Typhoid  Fever,  Chap.  XIV.) 

Diet. 

3,000  calories  or  more  if  desired  by  patient. 
(For  details,  see  Typhoid  Fever,  Chap.  XIV.) 

Fluids. 

Offer  freely  fruit  juices  and  alkaline  waters. 

Bowels. 

Initial  cathartic  of  castor  oil,  5ss.-i  (15-30  c.c.)  or 

Salts;  Epsom,  Rochelle  or  Glauber's,  gss.-i  (15-30  Gm.). 

Calomel  gr.  iss.-ii  (0.10-0.120  Gm.).    May  be  given  in  divided  doses 

of  gr.  1/4  (0.015  Gm.)  at  quarter-hour  intervals. 
Enemata  or  mild  cathartics  in  later  stages. 


RAT-BITE  FEVER  749 

Pains  and  aches. 

Acetyl  salicylic  acid  (aspirin)  gr.  x  (0.66  Gm.). 
Acetanilid,  gr.  ii  to  iii  (0.120-0.20  Gm.). 

Any  one  of  these  is  given  at  two  to  three  hour  intervals. 
Excellent  results  are  obtained  by  using  small  doses  at  frequent  inter- 
vals; e.  g.,  acetanilid  gr.  iss.  at  1/2  hour  intervals  for  six  doses,  then 

every  two  hours  for  six  doses. 
Use  no  coal  tars  except  in  the  sthenic  period  and  when  the  circulation 

is  good. 
May  be  combined  with  sodium  bicarbonate  and  citrated  caffeine  in 

small  doses. 
If  results  are  not  obtained,  use  codeine  phosphate,  gr.  1/8  to  gr.  1/2 

(0.008  to  0.030  Gm.); 

or  if  necessary  use  morphine  sulphate,  gr.  1/12  (0.005  Gm.)  hypoder- 

mically.    Increase  the  dose  sparingly. 

Sleeplessness. 

Begin  with  milder  hypnotics.    Bromides,  gr.  xv-gr.  xxx. 
Acetphenetidin  (phenacetin)  gr.  iii  to  v  (0.20-0.30  Gm.). 

Delirium. 

Morphine  sulphate gr.  1/4          (0.015  Gm.). 

Hyoscine  hydrobromide gr.  1/200      (0.0003  Gm.). 

Nervousness. 

Bromides  small  doses gr.  x  to  xv         (0.66-1  Gm.). 

Trional  gr.  ii  (0.120  Gm.)  every  two  hours  during  the  day. 
Luminal  gr.  1/2  (0.030  Gm.)  three  times  a  day. 

Dizziness. 
Bromides  as  above. 

Fever. 

Cold  sponges  or  packs. 

(See  Scarlet  Fever,  Chap.  XVII.) 

Skin. 

Cleanliness. 
Drying  powders. 

Circulation. 

Digitalis.    (See  Pneumonia,  Chap.  IX.) 

Specific  Treatment. 
Salvarsan  administered  as  in  syphilis,  intravenously,  0.40  Gm.  to 

females  and  0.60  Gm.  to  males. 
Mercury. 


750          TREATMENT  OF  ACUTE  INFECTIOUS  DISEASES 
Anemia. 

Iron  as  Vallet's  mass  gr.  x  three  times  a  day. 

May  add  arsenious  acid,  gr.  1/40-1/20  (0.0015-0.003  Gm.). 

Sodium  cacodylate,  gr.  ss.-i  (0.0020-0.060  Gm.), 

Green  citrate  of  iron  gr.  3/4  (0.05  Gm.)  three  times  a  day. 

Convalescence. 

Fresh  air  sunlight,  good  food. 
Treatment  of  anemia. 

Prophylaxis. 
Cauterization  with  fuming  nitric  acid  thoroughly. 


CHAPTER  XLIV 

TRENCH  FEVER 

A  DISEASE  which,  contracted  in  the  trenches  of  the  great  war,  gets  its 
name  from  the  fact.  It  is  essentially  a  military  problem.  It  will  be  appre- 
ciated from  the  brief  description  that  follows  that  its  mode  of  conveyance 
and  spread  demand  certain  conditions  peculiarly  favored  by  the  exigencies 
of  a  military  campaign;  but,  no  doubt,  now  that  the  war  has  stamped 
its  picture  on  our  minds  it  may  be  appreciated  as  the  cause  of  certain 
obscure  fevers  of  civil  life.  The  disease  is  conveyed  by  the  body  louse. 
The  virus  is  present  in  the  feces  of  this  parasite  and  is  very  resistant, 
withstanding  drying  of  the  feces.  At  first  it  was  believed  that  the  only 
method  of  inoculation  was  through  excoriations  caused  by  scratching, 
but  it  has  been  shown  that  it  also  may  be  conveyed  by  the  bite  of  the 
louse.  It  is  a  filterable  virus  (Swift).  It  requires  an  incubation  period  in 
the  louse  of  7  to  8  days.  The  louse  remains  infective  up  to  three  weeks 
after  its  infection  and  possibly  longer.  The  incubation  period  in  man  is 
5  to  20  days.  There  are  very  few  at  any  age  who  are  immune  to  the 
disease  and  the  immunity  after  an  attack  is  very  short  lived,  in  some 
instances  barely  outlasting  the  attack. 

Symptomatology.  This  varies  greatly  in  individual  cases.  It  is 
characterized  by  the  general  discomforts  attendant  upon  most  acute 
infectious  processes,  so  striking  in  some  cases  as  to  be  likened  to  in- 
fluenza with  its  headaches,  backaches  and  pains  in  the  extremities,  and 
flares  in  temperature  or  to  Dengue  with  its  severe  pains  in  the  extremi- 
ties and  post  orbital  pains;  an  illusion  heightened  by  the  saddle-back 
temperature  of  some  of  the  cases,  relatively  slow  pulse  and  its  rash.  This 
sudden  onset  occurs  in  about  half  the  cases.  Shin  pains  seem  quite 
characteristic,  even  if  not  constant,  and  pain  in  muscles  and  joints  may 
be  mistaken  for  rheumatism.  The  conjunctiva?  are  injected.  Some 
authors  speak  of  lateral  nystagmus  as  characteristic;  others  as  being  no 
more  common  than  in  other  acute  diseases.  Giddiness  may  be  a  feature 
of  the  onset.  Sweating  and  polyuria  may  occur. 

The  pulse  is  relatively  slow  in  comparison  with  temperature,  though 
some  observers  find  its  acceleration  corresponds  with  the  temperature; 
the  spleen  is  enlarged  and  palpable;  a  characteristic,  but  evanescent 
rash  occurs  in  the  early  febrile  periods.  It  consists  of  small  macules 


752  TREATMENT  OF  ACUTE  INFECTIOUS  DISEASES 

like  rose  spots,  disappearing  on  pressure  and  distributed  especially  on  the 
trunk,  coming  in  crops  in  each  relapse. 

The  blood  usually  shows  a  leucocytosis,  14,000-16,000,  large  mono- 
nuclears  and  lymphocytes  are  relatively  increased,  though  in  some  cases 
decided  leucopenia  is  observed.  Leucocytosis  is  the  rule  with  the  fever, 
and  mononuclear  increase  in  the  afebrile  periods.  The  temperature 
may  be  continuous,  of  short  duration,  or  lasting  two  or  three  weeks  and 
resembling  a  typhoid  or  paratyphoid  fever  curve;  on  the  other  hand  it 
may  be  interrupted,  a  relapsing  type  of  temperature;  there  are  three  or 
four  days  of  fever,  12  to  24  hours  of  normal  temperature,  another  period 
of  from  3-4  days  and  recovery,  or  with  shorter  febrile  periods  of  24  to 
30  hours  occurring  at  intervals  of  5-6  days. 

Prognosis.  The  prognosis  is  good.  The  disease  is  not  fatal;  about 
90  per  cent,  get  well  promptly  on  symptomatic  treatment;  10  per  cent, 
run  a  long  course. 

Treatment.  Even  if  delousing  has  been  accomplished,  isolation  is 
necessary,  as  the  infection  is  conveyed  not  only  by  the  louse,  but  by 
the  virus  excreted  with  the  urine  and  saliva  of  the  patient. 

If  a  case  were  seen  in  civil  practice,  one  would  urge  the  necessity  of 
rest  in  bed,  even  in  the  lighter  cases,  as  probably  having  a  beneficial 
effect  on  the  course.  The  choice  of  room,  bed,  care  of  patient,  and 
preliminary  catharsis  with  enemas  and  light  cathartics  later  are  deter- 
mined by  the  same  considerations  and  exercised  in  the  same  manner  as 
in  Typhoid  or  Pneumonia  or  Influenza.  (See  Chaps.  XIV  or  IX 
and  XII.) 

The  urine  and  sputum,  both  of  which  are  infectious,  should  be  de- 
stroyed by  heat  or  the  use  of  such  antiseptics  as  cresol  or  lysol.  (See 
Typhoid  Fever,  Chap.  XIV.) 

The  diet  should  be  sufficient  to  meet  the  caloric  needs  of  the  patient 
(see  Chap.  II)  and  chosen  much  as  Typhoid  Fever.  (See  Chap.  XIV.) 
Water  should  be  freely  administered,  or  fruit  drinks,  lemonade,  orange- 
ade or  alkaline  drinks. 

Aches  and  pains  are  to  be  met  by  the  use  of  aspirin,  the  coal  tars, 
acetphenetidin  (phenacetin),  acetanilid,  antipyrin  or  in  more  severe 
cases  by  codeine  or  even  morphine,  for  the  detailed  administration  of 
which  see  Grippe  (Chap.  XI). 

Insomnia.  For  use  of  hypnotics,  consult  Chapters  on  Grippe  (XI), 
or  Pneumonia  (IX)  or  their  summaries. 

Nervousness.  May  be  lessened  by  warm  sponge  baths  and  the 
administration  of  bromides. 

In  long  standing  cases  anemia  ensues.  This  should  be  met  with  a 
sufficiency  of  good  food,  air,  sunlight  and  the  use  of  iron,  as  Vallet's 


TRENCH  FEVER  753 

mass  or  Eland's  pills  gr.  x  (0.66  Gm.)  three  times  a  day  with  arsenic,  as 
arsenious  acid  gr.  1/40  (0.0015  Gm.)  at  the  same  intervals,  combined 
with  iron  or  as  cacodylate  of  soda  hypodermically,  gr.  ss.-i  (0.03-0006 
Gm.)  a  day. 

Considering  that  spirochetes  have  been  suspected  as  the  infecting 
organism  it  seemed  reasonable  to  try  arsphenamine  (salvarsan),  but 
its  use  was  not  followed  by  gratifying  results. 

Serum  from  convalescent  cases  was  administered  without  success. 

Richter  reported  that  the  intravenous  injection  of  10  c.c.  of  1  per  cent, 
collargol  every  two  or  three  days  during  the  acute  stages  was  followed 
by  a  rapid  cure.  (Quoted  from  Swift.) 

Complications  and  sequelae.  A  large  percentage  of  cases  of  D.  A. 
H.  (disordered  action  of  the  heart)  or  cardio-vascular  asthenia  or  effort 
syndrome,  in  the  British  Army  had  trench  fever,  which  played  its  role 
in  all  probability  in  the  acquisition  of  that  condition.  Small  doses 
of  thyroid  have  been  recommended  as  likely  to  lessen  the  incidence  of 
this  condition.  Leg  pains  and  lumbar  pains  were  sometimes  exceedingly 
persistent. 

The  patient  should  not  be  discharged  until  the  dangers  of  relapses 
have  probably  passed,  as  he  will  constitute  a  pool  of  virus  for  the  in- 
fection of  lice  and  so  of  other  individuals  in  contact  with  him. 

He  should  be  kept  in  bed  at  least  a  week  after  the  last  relapse.  He 
should  then  be  gotten  up  gradually  and  put  through  graduated  exercises. 
A  change  of  environment,  fresh  air,  sunlight,  good  food  are  all  helpful. 
The  convalescence  is  often  slow  and  some  five  per  cent,  manifest  the 
neurasthenic  symptoms  mentioned  as  a  sequel  and  which  probably 
represent  continued  infection.  These  cases  require  much  attention,  tact 
and  ingenuity  in  the  handling. 

Prophylaxis.  Trench  fever  is  transmitted  by  the  louse,  Pediculus 
Humanus,  and  hence  it  is  very  important  that  any  patient  suffering 
from  trench  fever  be  carefully  deloused.  The  hair  of  his  head,  axillae, 
pubis  and  chest  should  be  shaved  and  burned.  The  patient  should  then 
be  bathed  with  warm  water  and  soap  followed  by  an  alcohol  (50  per 
cent.)  sponge.  He  should  then  be  put  to  bed  in  another  room  in  another 
bed  known  to  be  free  from  vermin.  The  patient  should  be  daily  in- 
spected for  nits  and  lice. 

The  room  previously  occupied  by  the  patient  and  all  articles  of 
furniture,  clothing,  bedding  and  mattress  should  be  disinfected  even 
though  there  is  no  trace  of  lice,  for  the  virus  of  trench  fever  is  excreted  in 
the  urine  and  saliva  of  patients  and  in  the  feces  of  the  louse  and  may 
still  be  viable.  Those  who  carry  out  the  disinfection  should  wear  rubber 
gloves  and  avoid  rubbing  the  contaminated  material  on  the  skin. 


754  TREATMENT  OF  ACUTE  INFECTIOUS  DISEASES 

Disinfection  may  be  effected  by  moist  heat  at  a  temperature  not  lower 
than  120°  F.  for  one-half  hour. 

All  persons  who  have  been  in  contact  with  patients  should  be  ex- 
amined for  lice  and  nits  and  if  infected  should  be  deloused  and  watched 
for  30  days,  for  a  person  may  develop  the  disease  after  he  is  freed  from 
the  lice. 

Bedding  and  mattresses  as  well  and  clothing  should  be  disinfected  by 
heat.  (See  Typhus  Fever,  Chap.  XXVIII.) 

If  heat  is  not  used,  soaking  in  a  2  per  cent,  solution  of  liquor  saponatus 
cresoli  fortis  or  2  per  cent,  solution  of  crude  phenol  and  soft  soap,  equal 
parts  at  any  temperature  above '32°  C.  for  20  minutes  or  1  per  cent, 
solution  at  60°  C.  to  63°  C.  for  20  minutes. 

The  patient  once  infected  is  a  source  of  virus  and  as  the  case  is  often 
chronic  and  the  relapses  very  far  apart,  carriers  of  this  virus  are  pretty 
sure  to  carry  the  disease  into  civil  life. 

SUMMARY 

Treatment 

Isolate  the  patient  until  del ousing  is  completed;  when  this  is  accom- 
plished isolation  is  no  longer  necessary. 
Rest  in  bed. 

H  I  (See  Typhoid  Fever,  Chap.  XIV,  Pneumonia, 

Care  of  patient    '       ChaP'  IX>  or  Influenza>  ChaP-  XIL> 
Catharsis. 

Diet. 

Should  contain  3,000  or  more  calories  if  well  taken.    (For  items  of 
dietary,  see  Typhoid  Fever,  Chap.  XIV.) 

Drinks. 

Water  freely,  lemonade,^orangeade,  alkaline  drinks,  weak  tea,  cocoa, 
buttermilk. 

Aches  and  pains. 
Acetyl  salicylic  acid  (Aspirin),  gr.  v-x  (0.33-0.66  Gm.),  every  2  or  3 

hours; 
or: 

Acetphenetidin  (Phenacetin),  gr.  iii-v  (0.2-0.33  Gm.); 
or: 

Antipyrin,  gr.  ii-iv  (0. 125-0.250. Gm.); 
or: 

Acetanilid,  gr.  iss.-gr.  iii  (0.10-0.2  Gm.)  at  the  same  intervals. 
(See  also,  Grip,  Chap.  XI.) 


TRENCH  FEVER  755 

In  severe  cases. 

Codeine  phosphate  or  sulphate,  gr.  1/8-1/2  (0.008-0.030  Gm.)  by 
mouth  or  hypodermically; 

or: 

Morphine  sulphate,  gr.  1/8-gr.  1/4  (0.008-0.015  Gm.),  hypodermic- 
ally; 

Insomnia. 

(For  choice  and  use  of  hypnotics,  see  Grippe,  Chap.  XI,  or  Pneumonia, 
Chap.  IX,  or  their  summaries.) 

Nervousness. 

Warm  sponge  baths. 

Bromides  in  doses  of  gr.  xv-xxx  (1-2  Gm.)  in  water. 

Anemia. 

Good  food  and  sufficient. 

Fresh  air  and  sunlight. 

Iron  as  Blaud's  pills  or  Vallet's  mass  (Massa  ferri  carbonatis)  gr.  x 

(0.66  Gm.). 

Arsenic — well  to  combine  it  with  the  iron. 
Arsenious  acid  (Arseni  trioxidum),  gr.  1/40  (0.0015  Gm.) 

Sodium  cacodylate,  gr.  ss.-i  (0.030-0.060  Gm.)  given  hypodermic- 

cally. 
Collargol. 

Intravenous  injection  of  10  c.c.  of  a  1  per  cent  solution,  every  2 
or  3  days  during  the  acute  stages.    (Richter.) 

Sequelae. 

Disordered  action  of  the  heart  (D.  A.  H.),  the  effort  syndrome  or 
cardio-vascular  neurasthenia.  Probably  represents  low-grade 
infection. 

Good  food,  fresh  air,  graduated  exercises,  tactful  handling. 
Small  doses  of  thyroid. 
Leg  pains  and  lumbar  pains. 
Local  measures. 
Aspirin  in  small  doses. 

Convalescence. 

Keep  in  bed  at  least  a  week  after  last  relapse. 

Get  up  gradually. 

Graduated  exercises. 

Good  food. 

Fresh  air. 

Change  of  environment,  if  possible. 

Prophylaxis. 

Delousing.     (See  Typhus  Fever,  Chap.  XXVIII.) 
Clothes  submitted  to  steam  under  pressure.     (See  Typhus  Fever, 
Chap.  XXVIII.) 


756  TREATMENT  OF  ACUTE  INFECTIOUS  DISEASES 

Shave  pubic  and  axillary  hair.    Cut  hair  on  head  close. 
Bedding  and  mattresses  submitted  to  heat;  steam  under  pressure. 
Bed  clothing  if  not  disinfected  by  heat  may  be  soaked  in  2  per  cent. 

solution  of  liquor  saponatus  cresoli  fortis. 
or: 
2  per  cent,  solution  of  crude  phenol  and  soft  soap,  equal  parts  at  any 

temperature  above  32°  C.  for  20  minutes; 
or: 
1  per  cent,  solution  at  60°  C.-63  C.  for  20  minutes. 


CHAPTER  XLV 

SEPTICAEMIA  AND  PYAEMIA 

ALTHOUGH  this  condition  affords  a  fairly  definite  picture,  it  is  by 
no  means  easy  of  definition. 

Septicaemia  is  a  state  of  infection  in  which  the  infecting  organism  is  not 
only  encountered  in  the  blood,  but  is  multiplying  there,  and  yet  evidences 
of  infection  with  recovery  of  the  infecting  organism  from  the  blood  does 
not  necessarily  constitute  a  septicaemia  but  may  exemplify  a  far  less 
serious  infection  called  bacteriaemia  and  the  same  organism  may  be 
concerned  in  one  or  the  other  condition.  For  example,  the  pneumococ- 
cus  may  be,  often  or  usually  is,  isolated  from  the  blood  of  a  lobar  pneu- 
monia and  its  presence  in  the  blood  in  no  way  modifies  the  picture, 
course  or  issue  of  the  pneumonia  or  on  the  other  hand  it  may  be  causal 
of  a  true  septicaemia. 

What  relationship  of  infecting  organism  and  host  determines  the 
relatively  innocuous  bacteriaemia  and  the  profoundly  serious  septi- 
caemia is  not  yet  clear. 

If  suppurative  foci  appear  in  a  septicaemia  the  process  is  spoken  of 
as  pyaemia. 

Toxaemia  is  a  term  used  to  express  the  effects  on  the  body  of  the 
toxins  or  products  of  bacterial  activity  irrespective  of  whether  that 
activity  is  local  in  some  tissue  or  general  throughout  the  body  in  the 
blood. 

As  the  essence  of  septicaemia  and  pyaemia  is  the  same  (presence  and 
multiplication  of  virulent  organisms  in  the  blood),  and  their  difference 
determined  only  by  the  presence  or  absence  of  multiple  suppurative 
foci  they  will  be  considered  together. 

The  organisms  commonly  responsible  for  septicaemia  are  strepto- 
cocci; and,  indeed,  it  is  a  streptococcus  septicaemia  that  the  unquali- 
fied term  "  septicaemia "  usually  connotes  to  the  ear  of  the  general 
practitioner,  but  the  invasion  of  the  blood  by  many  other  forms  of 
bacteria  may  constitute  a  septicaemia;  e.  g.,  the  staphylococci;  and  a 
staphylococcus  septicaemia  is  usually  characterized  by  the  multiplicity 
of  abscesses  accompanying  it  (pyaemia),  the  pneumococci,  the  gonococci, 
the  typhoid  bacilli,  the  colon  bacilli,  the  influenza  bacilli,  pyocyaneus, 
proteus,  Friedlander's  bacillus,  micrococcus  tetragenus,  anthrax,  bacillus 
aerogenes  capsulatus,  meningococcus. 


758  TREATMENT  OF  ACUTE  INFECTIOUS  DISEASES 

The  general  symptoms  of  septicaemia  and. pyaemia  (septico-pyaemia) 
are  due  to  the  toxaemia;  and  the  focal  and  local  lesions  to  the  thrombo- 
phlebitis and  emboli  producing  infarcts,  and  abscesses.  The.  valves  of 
the  heart  and  adjacent  structures,  like  the  veins,  may  be  the  seat  of 
bacterial  activity  and  furnish  infective  thrombi  (bacterial  or  ulcerative 
or  malignant  endocarditis) ;  and  the  effects  they  have  upon  the  organs 
concerned  constitute  the  pathology  of  the  disease. 

The  early  symptoms  are  due  to  the  toxaemia  and  the  toxaemia  is 
intense;  and,  in  the  absence  of  a  local  lesion,  suggest  one  of  several 
conditions  such  as  typhoid  fever,  acute  miliary  tuberculosis,  pneu- 
monia with  tardy  consolidation,  aestivo-autumnal  malarial  fever. 

In  children  B.  coli  pyelitis  and,  more  rarely,  grippe  and  otitis  media 
simulate  a  septicaemia. 

A  more  accurate  diagnosis  in  the  early  stage  awaits  the  result  of  blood 
examination;  its  cytology,  serum  reactions  and  most  of  all  its  culture 
returns. 

Later,  heart  murmurs,  hemorrhagic  spots  (petechijse) ,  splenic,  pul- 
monary and  renal  infarcts,  cerebral  embolism,  suppurative  foci,  retinal 
hemorrhages,  assure  a  septicaemia;  while  the  other  suspected  conditions 
would  take  on  gradually  their  classic  characterization. 

The  early  symptoms  are  fever,  often  initiated  by  chills  (and  the 
chills  may  be  repeated  or  long  continued,  and,  indeed,  are  character- 
istic of  pyaemia);  loss  of  appetite,  delirium  or  stupor  or  the  typhoid 
state. 

TREATMENT 

Rest.  Insistency  on  rest  in  its  broadest  significance  should  be 
considered  imperative.  This  means  a  quiet  room,  comfortable  bed, 
competent  nursing,  freedom  from  worries  and  anxieties,  exclusion  of 
visitors. 

Room.  Whether  in  the  house  or  in  the  hospital,  it  should  be  chosen 
with  reference  to  light,  ventilation,  conveniences  of  bath-room,  access 
to  the  open  air  by  veranda  or  porch,  and  remoteness  from  the  noises  of 
the  street  and  of  the  household.  Light  is  an  important  therapeutic 
agent,  the  operation  of  which  is  too  little  known  in  its  details.  In- 
dividuals respond  differently  to  light  both  in  its  quality  and  quantity. 
One  has  but  to  consult  his  own  personal  experiences  in  health  to  realize 
what  an  extraordinary  effect  upon  our  moods  and  emotions  and  so  upon 
our  bodily  functions  light  and  shade,  sunshine  and  shadow  have,  aside 
from  the  direct  effects  of  the  rays  of  light  upon  the  body  cells  themselves. 
In  disease  these  effects  of  light  should  be  taken  into  consideration  and 


SEPTICAEMIA  AND  PYAEMIA  759 

the  grateful  effects  of  morning  or  evening  sun  and  the  irritating  action  of 
the  noon-day  glare  be  provided  for  or  avoided. 

The  destructive  effect  of  sunlight  on  germ  life  is  too  well  known  to 
dilate  upon  here. 

Fresh  Air.  Maximum  ventilation  is  desirable  and  a  corner  room 
with  a  number  of  windows  affords  this.  All  that  has  been  said  of  fresh 
air  in  pneumonia  obtains  here  both  as  regards  the  rationale  of  its  thera- 
peutic action  and  the  technique  of  exposing  the  patient  to  the  open  air. 
(See  Pneumonia,  Chap.  IX.) 

The  room  should  be  stripped  of  all  unnecessary  furnishings  and  be 
devoted  entirely  to  the  patient. 

The  use  of  the  same  room  to  sleep  or  rest  in  by  the  nurse  is  to  be 
deprecated  because  of  the  bad  results  to  both  in  ways  readily  imagined. 

If  it  is  not  possible  to  have  more  than  one  nurse,  she  should  be  re- 
lieved at  suitable  periods  by  members  of  the  family,  to  secure  her  rest 
in  a  quiet  room  remote  from  the  scene  of  her  duties. 

Bed.      For  details,  see  Pneumonia,  Chap.  IX. 

Diet.  While  the  most  virulent  cases  of  septicaemia  run  a  rapid 
course  and  are  accompanied  by  anorexia  that  makes  feeding  very 
difficult,  the  vast  majority  run  a  fairly  long  course  that  compels  knowl- 
edge of  the  theoretical  needs  of  the  patient  and  the  arrangement  of  a 
dietary  to  meet  them.  The  theoretical  needs  have  been  detailed  in 
Chap.  II,  while  arrangements  of  dietaries  to  fulfil  them  may  be  seen 
under  Typhoid  Fever,  Chap.  XIV,  Pneumonia,  Chap.  IX,  and  else- 
where. (Consult  Summaries.) 

To  epitomize,  we  endeavor  to  achieve  3,000  calories  daily  in  the 
diet  and  as  much  more  as  the  patient  handles  well.  The  proteid  con- 
tent should  be  about  80  grams,  but  need  not  be  rigidly  fixed ;  milk,  eggs, 
bread,  cereals,  broths  (especially  those  fortified  with  farinaceous  flours), 
purees,  form  the  basis  of  this  diet  and  the  use  of  sugar  in  the  milk,  in 
jellies,  on  cereals,  in  fruit  drinks,  and  the  use  of  fats,  such  as  cream  in  the 
milk,  on  cereals  and  butter  on  bread  add  to  the  caloric  content  of  the 
diet. 

Variety  is  secured  by  using  various  milk  preparations;  butter-milk, 
koumys,  matzoon,  zoolak,  junket,  ice-cream;  of  eggs  by  preparing  them 
in  different  forms;  coddled,  custard,  egg-nog,  egg-white,  poached;  of 
cereals  by  using  different  kinds,  incorporating  them  in  broths,  or  as  some 
of  the  invalid  or  infant  foods,  so  numerous  on  the  market;  the  bread  as 
bread  and  butter,  toast,  dry  or  wet,  milk  toast,  bread  and  milk,  crackers, 
biscuit. 

Frequency  of  feeding  should  be  every  two  or  three  hours  as  the  patients 
bear  it  best. 


760  TREATMENT  OF  ACUTE  INFECTIOUS  DISEASES 

Fluids  should  be  given  in  abundance;  alUthat  the  patients  want 
and  to  those  delirious,  stuporous  or  too  sick  to  ask  for  it,  it  should 
be  offered  at  least  every  hour.  It  may  be  given  as  water,  plain,  or  if 
grateful,  aerated;  as  lemonade,  orangeade  or  other  diluted  fruit  juices 
or  Imperial  drink.  (See  summary  for  formula.) 

When  first  seen  the  bowels  should  be  freely  opened  either  by  castor 
oil  or  a  salt,  Epsom,  Rochelle,  sodium  phosphate,  in  doses  of  one  or  the 
other  of  gss.-l  (15-30  c.c.  or  Gm.)  or  by  calomel  gr.  ii  (0.12  Gm.),  best 
in  divided  doses,  followed  by  the  above  or  by  Hunyadi  or  equivalent 
water,  or  milk  of  magnesia  gi  to  ii  (30-60  c.c.)  or  liquor  magnesii  citratis 
5viii-xii  (240-360  c.c.).  Later  the  bowels  should  be  kept  open  by  the 
use  of  the  milder  salines  mentioned  above  or  by  enemata. 

Care  of  the  Body.  For  all  the  details  of  care  of  skin,  mouth,  nose, 
eyes,  genitals,  consult  Pneumonia,  Chap.  IX,  or  Typhoid  Fever, 
Chap.  XIV,  or  the  Summaries. 

Local  suppurative  processes  in  pyaemia,  of  course,  indicate  surgical 
procedures. 

SYMPTOMATIC  TREATMENT 

Fever.  The  nature  of  the  infecting  organism,  the  virulency  of  the 
toxins,  the  presence  or  absence  of  suppurative  foci,  all  determine  differ- 
ences in  the  fever  curve.  The  temperature  may  run  continuously  high 
with  slight  excursions,  or  show  wide  excursions,  accompanied  by  rigors 
and  sweating,  especially  in  pyaemia,  or  may  be  relatively  low  in  the  more 
chronic  cases. 

Hyperpyrexia  but  rarely  occurs;  but  a  sustained  high  temperature 
of  104°  F.  to  105°  F.  is  more  common  and  has  the  same  deleterious 
effect  upon  the  vital  centres.  These  cases  indicate  the  local  appli- 
cation of  cold  in  the  shape  of  cold  packs  or  cold  sponges  repeated  at 
three  to  four  hour  intervals  if  necessary,  and  prolonged  until  some 
effect  is  made  upon  the  temperature.  The  most  beneficial  effects  of 
these  baths  is  upon  the  circulatory  and  nervous  system.  When  the 
rise  of  temperature  is  initiated  by  a  chill,  hot  drinks  may  be  administered 
and  heat  applied  to  the  feet  and  body  surface  until  the  rigor  has  passed. 

The  sweats  that  follow  the  febrile  exacerbations  call  for  luke  warm 
sponges,  change  of  linen  and  application  of  sterile  dusting  powders. 

Sometimes  the  excursions  are  so  tremendous  that  collapse  may 
ensue  and  demand  the  application  of  heat,  hot  drinks,  diffusible  stimu- 
lants, such  as  the  stronger  water  of  ammonia  held  near  the  nose  on  a 
towel,  hypodermics  of  adrenalin,  camphor  or  caffeine  or  strophanthin. 

At  the  onset  there  may  be  some  vomiting,  but  as  a  rule  this  is  not 


SEPTICAEMIA  AND  PYAEMIA  761 

prolonged  or  violent  enough  to  demand  interference.  Cracked  ice  may 
be  sucked  and  counter-irritation  applied  to  the  epigastrium  in  the  shape 
of  mustard  paste. 

Should  it  become  more  persistent,  as  it  may,  one  has  to  modify  the 
diet,  giving  the  food  in  smaller  quantities  more  frequently,  cutting 
down  the  cream  in  the  milk  or  lessening  the  intake  of  sugar,  trying 
various  modifications  of  milk.  If  the  stomach  tube  is  well  borne, 
lavage  with  warm  water  may  be  helpful  and  the  food  administered  by  the 
tube. 

In  persistent  cases  rectal  feeding  may  be  required. 

Nervous  Symptoms.  Restlessness,  insomnia,  stupor,  delirium, 
headaches  are  all  common. 

Delirium  may  be  low,  muttering,  a  typhoid  state  or  noisy  and  wild. 

The  items  of  importance  to  be  considered  in  this  state  are  fresh  air, 
cold  sponges  or  packs,  a  sufficiency  of  food  and  particularly  an  abun- 
dance of  water.  When  it  is  difficult  to  give  the  patient  enough  by  the 
mouth  (3  to  5  quarts)  one  should  have  recourse  to  colonic  irrigations 
and  especially  the  drip  or  drop  method  of  Murphy. 

Noisy  delirium  is  also  to  be  combated  by  the  application  of  the 
ice-bag  to  the  head. 

The  patient  should  never  be  left  alone,  lest  he  do  himself  harm 
and  in  the  wild  cases  restraint  becomes  necessary.  The  most  humane 
method  is  by  so  attaching  the  bed  covers  to  the  side  of  the  bed  that  his 
hands  and  arms  cannot  escape  or  the  patient  sit  up,  but  allowing 
his  body  some  freedom  of  movement.  At  times  it  is  imperative  to  tie 
the  extremities  to  the  bed;  knots  must  be  so  made  that  they  will  not 
slip  and  tighten  upon  the  wrists  and  ankles  to  their  injury. 

Drugs.  At  times  are  necessary.  If  the  condition  is  one  rather 
of  restlessness  and  excitability  bromides  in  doses  of  15-30  grains  (1-2 
Gm.) ;  either  the  potassium  salt  or  the  mixed  salts  of  potassium,  sodium 
and  ammonium  in  equal  parts  may  be  administered  late  in  the  after- 
noon and  repeated  in  the  evening,  as  the  condition  is  likely  to  be  worse 
at  this  time. 

In  more  severe  delirium  codeine  is  indicated,  best  as  the  soluble 
phosphate  in  doses  of  gr.  1/4  (0.015  Gm.)  hypodermically.  In  still 
more  severe  cases  morphine  is  indicated,  given  hypodermically  as  the 
sulphate  gr.  1/8  to  gr.  1/4  (0.008-0.015  Gm.)  or  Majendie's  solution 
m.  iv  to  m.  viii  (gr.  2/15-4/15;  0.008-0.015  Gm.  morphine). 

If  morphine  is  not  well  borne  or  excites  as  it  does  in  the  rare  case, 
one  may  have  recourse  to  hyoscine  hydrobromide  in  doses  of  gr.  1/200 
to  gr.  1/100  (0.0003-0.0006  Gm.)  hypodermically. 

Insomnia  is  met  by  much  the  same  measures,  ice  to  the  head,  hot 


762  TREATMENT  OF  ACUTE  INFECTIOUS  DISEASES 

drinks,  heat  to  the  feet,  if  they  are  cold,  and  this  is  especially  so  in 
young  subjects;  by  bromides,  trional  gr.  xv  '(I  Gm.),  chloralamid  gr. 
xxx  (2  Gm.),  any  one  of  which  may  be  repeated  in  two  or  three  hours, 
or  by  codeine  and  morphine. 

Headaches  may  be  due  to  the  iriitating  effects  of  the  toxins  or  to 
a  localization  of  bacterial  activity  in  the  brain  or  its  coverings.  It 
may  be  relieved  by  the  application  of  an  ice-bag  or  ice-coil  or  by  the 
use  of  drugs.  The  use  of  coal  tar  derivatives  is  to  be  deprecated  as 
depressing  to  the  circulation.  A  very  severe  headache  is  better  controlled 
by  morphine. 

Convulsions  may  occur,  but  are  due  in  most  cases  to  thrombo- 
phlebitis or  embolism  and  not  likely  to  be  repeated  or  prolonged.  Mor- 
phine sulphate  hypodermically  in  doses  of  gr.  1/4  to  gr.  1/3  (0.015-0.02 
Gm.)  is  the  best  emergency  drug.  If  convulsions  are  repeated  the  same 
procedures  are  indicated  as  in  convulsions  from  other  causes.  (See 
Scarlet  Fever,  Chap.  XVII.) 

Circulation.  Sooner  or  later  the  circulatory  apparatus  is  imperilled 
either  by  the  effects  of  the  toxins  on  the  centres  or  on  the  myocardium 
or  by  a  localization  of  the  process  on  the  endocardium,  a  malignant 
endocarditis. 

For  a  detailed  use  of  circulatory  stimulants,  see  Pneumonia,  Chap. 
IX.  It  is  my  growing  belief  that  the  value  of  no  circulatory  stimulant 
in  acute  infectious  disease  is  comparable  to  digitalis  and  strophanthin. 
The  latter  I  use  in  emergency  gr.  1/90  to  gr.  1/60  (0.00075-0.001  Gm.) 
intramuscularly  or  intravenously  and  repeat  in  six  to  twelve  hours  if 
needed.  Follow  with  digitalis  m.  xxx  (2  c.c.)  of  the  tincture  [=gr.  iii 
(0.2  Gm.)  of  the  leaf]  or  its  equivalent  in  dosage  of  some  other  official 
preparation  three  or  four  times  a  day  until  its  pharmacological  or  toxic 
action  is  obvious. 

I  do  not  believe  in  the  use  of  alcohol. 

Further  treatment  is  directed  to  the  accidents  of  the  disease.  These 
are  determined  by  localization  of  the  process  by  thrombophlebitis,  by 
embolism  and  in  pyaemia  by  suppurative  foci. 

The  process  may  localize  on  the  endocardium  or  may  originate  at 
this  site  and  the  treatment  becomes  that  of  malignant  endocarditis, 
its  attendant  embolisms  and  circulatory  impairment. 

It  may  localize  upon  the  brain,  giving  rise  to  a  meningitis,  and  is 
to  be  treated  like  a  cerebro-spinal  meningitis  (see  Chap.  XXV)  symp- 
tomatically. 

Thrombophlebitis  may  occur  in  the  veins  of  the  extremities  and 
demand  rest,  slight  elevation  of  extremities,  applications  of  heat,  as 
fomentations,  and  protection  with  cotton  batten. 


SEPTICAEMIA  AND  PYAEMIA  763 

Thrombophlebitis  may  occur  in  deeper  organs,  giving  rise  to  second- 
ary results.  It  is  this  occlusion  of  the  vein  by  inflammatory  products 
that  furnishes  a  nidus  for  the  organism  and  with  the  heart  valves  fur- 
nishes the  infective  emboli,  which  are  carried  to  the  brain  and  cause 
hemiplegia,  monoplegia,  aphasia  or  other  disturbances  of  cerebral 
function. 

The  treatment  is  only  tentative.  Emboli  may  plug  the  central 
artery  of  the  eye  and  cause  blindness,  plug  the  pulmonary  arteries  and 
cause  infarcts  or  abscesses  and  empyema;  may  plug  the  coronary 
arteries,  giving  rise  to  sudden  and  alarming  symptoms  of  dyspnoea 
and  precordial  distress  or  even  death.  Treatment  of  conditions  follow- 
ing pulmonary  infarcts  is  that  of  Pneumonia  (see  Chap.  IX)  with  surgical 
intervention  when  suppuration  intervenes. 

Splenic  infarcts  are  common;  often  of  diagnostic  import.  The  pain 
accompanying  them  is  relieved  by  local  applications  of  heat  or  in  the 
worst  cases  by  morphine. 

The  veins  of  the  liver  may  become  involved  and  a  pylephlebitis, 
giving  the  worst  prognosis,  ensue. 

The  abdominal  viscera  may  become  involved  and  abscesses  result. 
Visceral  abscesses,  pylephlebitis,  meningitis  and  endocarditis,  all, 
are  of  the  most  ominous  significance. 

The  bones  may  be  affected  and  osteomyelitis  demand  surgical  inter- 
ference. 

The  joints  may  be  the  site  of  a  mild  arthritis  and  should  be  treated 
as  such  (see  Rheumatic  Fever,  Chap.  Ill)  or  may  suppurate  and  need 
evacuation.  The  muscles  and  skin,  especially  in  staphylococcus  in- 
fection, may  be  the  site  of  multiple  abscesses  and  require  incision. 

The  kidneys  may  become  involved.  Infarcts  with  hematuria  occur, 
needing  only  expectant  treatment,  or  an  acute  nephritis,  to  be  treated 
as  such  (see  Scarlet  Fever,  Chap.  XVII),  or  the  kidneys  become  the 
site  of  suppuration  and,  if  localized,  are  amenable  to  surgery. 

Hemorrhages  into  the  skin,  petechiae,  are  highly  diagnostic,  espe- 
cially those  in  the  conjunctive.  These  latter  occur  peculiarly  when 
the  heart  is  involved. 

Erythemata  also  occur  and  icterus,  but  none  of  these  require  treat- 
ment. 

In  pyaemia  the  original  site  of  infection  and  abscesses  secondary 
to  the  infection  indicate,  of  course,  surgical  measures. 

Certain  differences  depend  on  the  nature  of  the  infecting  or- 
ganism. 

Of  the  common  forms  of  infection  streptococcus  septicaemia  is  sup- 
posed to  be  the  worst,  though  there  is  little  difference  in  prognosis 


764  TREATMENT  OF  ACUTE  INFECTIOUS  DISEASES 

between  it  and  staphylococcus  septicaemia,  if,  indeed,  the  latter  is  not 
the  worse. 

Streptococci  affecting  the  heart  valves,  or.  the  meninges  or  causing 
pylephlebitis  or  visceral  abscess  lead  to  an  almost  certainly  fatal  issue; 
although  endocarditis  of  the  more  chronic  type,  "endocarditis  lenta," 
"bacterial  endocarditis,"  due  to  the  streptococcus  viridans  of  Schot- 
muller  seems  occasionally  to  get  well  and  even  one  apparently  true  case 
of  streptococcus  meningitis  has  been  reported  cured. 

Particularly  ominous,  too,  are  the  streptococcus  septicaemias  oc- 
curring in  small  pox,  scarlet  fever,  diphtheria  and  secondary  to  sur- 
gical procedure. 

Of  better  prognosis  is  the  streptococcus  septicaemias  of  the  puerperium. 

Staphylococcus  Septicaemia  is  almost  certainly  fatal,  its  course 
being  characterized  by  multiple  abscesses. 

Pneumococcus  septicaemia  gives  little  chance  of  cure. 

Among  other  forms  of  septicaemia  are  those  due  to  diphtheria  ba- 
cilli (though  streptococcus,  staphylococcus  and  pneumococcus  are 
commonly  recovered  from  the  blood  with  it),  to  typhoid  bacilli,  colon 
bacilli,  bacillus  pyocyaneus,  meningococci,  bacilli  dysenteriae  and  even 
bacilli  fusiformis. 

Specific  Treatment.  For  only  two  of  the  organisms  mentioned 
have  we  specific  sera,  bacillus  diphtheriae  and  pneumococcus  type  I ;  for 
some  of  the  others,  sera  containing  certain  dimly  visualized  antibodies 
have  been  elaborated. 

Scarlet  Fever.  Streptococci  may  be  recovered  from  many  cases 
that  run  a  relatively  mild  course,. a  bacteriaemia,  and  it  is  difficult  to 
establish  a  criterion  for  true  septicaemia  in  the  sense  of  this  discussion 
and,  hence,  to  judge  of  the  efficacy  of  streptococcic  sera. 

Nicoll,  discussing  this  subject,  accepts  a  certain  clinical  picture 
commencing  forty-eight  hours  or  longer  after  the  onset,  as  constituting 
sepsis;  "no  fall  of  temperature  or  a  renewed  rise;  abnormal  swelling 
of  the  mucous  membrane  of  the  throat;  with  or  without  superficial 
sloughing;  profuse  nasal  discharge;  marked  cervical  adenitis;  rapid, 
often  irregular  pulse;  mental  apathy;  active  or  low  delirium." 

He,  working  in  the  Scarlet  Fever  Hospital  of  the  Department  of 
Health  of  New  York  City,  used  a  serum  prepared  under  the  direction 
of  Dr.  Park.  Eleven  strains  of  streptococci  recovered  from  the  blood, 
throat  and  other  sources  from  scarlet  fever  patients  were  used  in  the 
animals  to  elaborate  this  serum;  hence,  a  polyvalent  serum. 

His  dose  of  this  particular  serum  was  200  c.c.;  in  young  children, 
50-100  c.c.  injected  into  loose  tissue,  repeated  2  to  3  times  at  6  to  8  hour 
intervals  depending  on  the  results  obtained. 


SEPTICAEMIA  AND  PY^MIA  765 

His  results  warrant  his  advice  to  use  the  serum  in  all  very  severe 
cases  of  scarlet  fever. 

Similar  efforts  with  polyvalent  sera  have  been  made  for  some  years 
past,  especially  in  European  clinics.  One  of  those  best  known  in  Europe 
is  the  Moser  serum  so  persistently  advocated  by  the  late  Professor 
Escherich  of  Vienna. 

My  own  impression  is  that  polyvalent  streptococcus  sera  are  well 
worth  using  in  this  condition,  with  the  realization  that  the  strains 
used  may  or  may  not  be  biologically  identical  with  the  organisms  re- 
sponsible for  the  individual  case;  hence,  may  be  more  or  less  efficacious, 
depending  in  a  measure  on  chance. 

The  dose  of  the  commercial  serum  is  that  used  by  Nicoll.  More 
recently  serum  from  patients  convalescent  from  scarlet  fever  has  been 
used  with  some  show  of  success.  The  dose  is  just  the  same  as  that  for  the 
commercial  sera. 

Vaccine  Therapy.  Our  knowledge  of  the  possibilities  and  limitations 
of  vaccine  therapy  is  too  limited  to  discuss  didactically  the  application 
of  this  measure  to  septicaemia. 

Reasoning  that  the  body  is  already  overwhelmed  with  virulent  toxins, 
and  that  the  addition  of  more  in  the  shape  of  vaccines  (endotoxins)  is 
illogical  we  pause  before  using  them;  on  the  other  hand  the  belief  that 
the  response  in  terms  of  antibodies  may  be  local  at  the  site  of  injection 
urges  us  to  take  a  chance.  Indeed,  its  use  in  the  severer  cases  is  that  of 
appeal  to  the  last  resort  and  is  so  far  justifiable,  but  then  only  with  a 
clear  knowledge  of  the  theory  and  uses  of  vaccine  therapy. 

In  the  more  chronic  cases  the  use  of  vaccines  is  more  encouraging 
and  some  cures  of  malignant  endocarditis  by  the  use  of  vaccines  have 
been  reported  from  reliable  sources. 

Autogenous  vaccines  should  be  used  when  possible.  If  the  organism 
cannot  be  recovered  from  the  blood,  local  lesion  or  other  reliable  source, 
one  may  use  a  .polyvalent  vaccine  with  a  lesser  expectation  of  success. 

Puerperal  Sepsis.  As  I  have  said  the  outlook  in  this  form  of  sepsis 
is  better  than  in  those  already  mentioned. 

Here  again  the  polyvalent  streptococcic  sera  may  be  used  in  the 
streptococcus  cases  and  the  vaccines,  too,  with  a  greater  hope  of  suc- 
cess, though  here,  too,  it  is  in  the  subacute  cases  that  the  best  results 
follow. 

G.  T.  Western,  studying  96  cases  of  puerperal  sepsis,  39  of  whom 
gave  positive  cultures  (36  were  streptococci),  treated  with  vaccine 
56  with  a  mortality  of  32  per  cent.,  and  treated  without  vaccines  44 
with  a  mortality  of  55  per  cent.  Even  better  results  have  been  reported 
by  others.  Others  report  less  enthusiastically.  I  imagine  that  in  this 


766  TREATMENT  OF  ACUTE  INFECTIOUS  DISEASES 

particular  form  of  sepsis  the  management  of  the  case  in  other  respects 
plays  a  major  part  in  the  results.  What  the  management  of  a  puerperal 
sepsis  case  should  be  I  am  not  competent  to  judge  in  the  midst  of  argu- 
ments pro  and  con,  but,  influenced  by  environment,  quote  Ward  from 
the  Sloan  Maternity  Hospital,  New  York:  "A.  Obtaining  adequate 
uterine  drainage,  first,  by  simple  vaginal  and  intrauterine  saline  douches. 
This  proving  insufficient  to  control  the  process,  explore  the  uterus  once, 
and  once  only  to  make  sure  it  is  empty  of  foreign  products,  using  the 
finger  for  the  exploration,  and  with  a  minimum  of  trauma  to  the  uterine 
tissues. 

"B.  Treat  expectantly  secondary  foci  as  they  arise,  and  C.  Sup- 
port the  general  condition  of  the  patient."  (J.  A.  M.  A.,  April  12, 
1913.) 

Staphylococcus  Septicaemia  may  be  treated  on  the  same  principles 
with  sera  and  vaccines  with  even  less  anticipation  of  results. 

Pneumococcus  Septicaemia.  Hope  from  sera  depends  on  the  de- 
termining strain. 

Grouping  pneumococci  according  to  the  classification  followed  at 
the  Rockefeller  Institute,  types  I  and  II  against  which  sera  have  been 
elaborated  may  be  combated  by  the  use  of  the  sera  as  in  Pneumonia, 
but  practically  it  has  been  found  that  type  I  serum  alone  is  efficacious. 

Types  III  (mucosus)  and  IV  (a  heterogenous  group)  yield  no  active 
sera. 

As  a  vaccine,  group  I  (Neufeldt)  may  be  used  as  in  pneumonia  and 
some  believe  that  the  antibodies  provoked  are  in  some  measure  operative 
against  the  other  organisms,  or  a  polyvalent  vaccine  may  be  used. 

Again  it  must  be  insisted  that  these  measures  are  adopted  by  the 
desire  to  leave  no  stone  unturned  rather  than  by  anticipation  of  favorable 
results. 

Gonococcus,  B.  coli,  streptococcus  mucosus  and  other  forms  of 
septicaemia  may  be  attacked  in  the  same  manner,  but  with  a  full  realiza- 
tion of  the  paucity  of  published  results  and  with  the  sense  of  responsi- 
bility towards  the  patient  in  handling  these  powerful  agents. 

Transfusion  of  Blood.  At  the  present  time  I  am  using  transfusion 
in  septicaemia  and  in  severe  infections  that  may  not  be  truly  classed 
as  such,  on  account  of  a  remarkable  experience  of  my  own,  the  first 
case  in  which  to  my  knowledge  the  method  was  used  for  this  purpose. 

A  case  of  sepsis  in  a  child  of  twelve,  seemingly  moribund,  recovering 
after  five  transfusions  from  the  father's  blood. 

The  case  is  reported  with  others  by  Dr.  Lindeman  in  the  Journal  of 
the  American  Medical  Association,  October  31,  1914. 

Reports  of  the  experience  of  others  since  and  my  own  observations 


SEPTICAEMIA  AND  PY^MIA  767 

of  improvement  in  other  cases  in  which  the  transfusion  has  been  done 
make  me  feel  that  the  measure  has  a  place  in  the  therapy  of  septicaemia. 

It  is  more  than  probable  that  the  blood  of  healthy  individuals  con- 
tain in  a  large  per  cent,  of  cases  immune  bodies  to  most  of  the  common 
infections. 

The  studies  of  the  antitoxin  content  of  normal  blood  by  the  Schick 
reaction  for  Diphtheria  reveals  such  astonishing  positive  results,  that 
in  the  absence  of  a  practical  test  for  other  immune  substances  the  use 
of  healthy  blood  would  seem  entirely  reasonable. 

In  addition  the  introduction  of  fresh  blood  must  be  welcome  to  the 
patient  in  an  anemic  state  so  decided  as  that  of  septicaemia,  while  other 
theoretical  considerations  could  be  cited  for  argument's  sake. 

My  experience  with  transfusion  leads  me  to  believe  that  its  value  lies 
in  its  application  to  those  diseases  whose  natural  history  is  to  recover 
under  favorable  conditions,  e.  g.,  it  would  be  of  value  in  puerperal  sepsis, 
while  it  holds  out  no  hope  in  cases  of  acute  malignant  endocarditis. 

Methods  of  transfusion  much  more  facile  than  the  old  direct  method 
have  been  elaborated  of  late  for  which  special  treatises  must.be  consulted. 
See  Lindeman,  Am.  Jour.  Diseases  of  Children,  Vol.  VI,  No.  1,  Lindeman, 
Jour.  A.  M.  A.,  June  7,  1919,  Vol.  72,  pp.  1661-1665;  Satterlee  and 
Hooker,  Archives  of  Internal  Medicine,  January,  1914,  and  Unger,  Jour. 
A.  M.  A.,  1915,  LXIV,  582;  Sanford,  Med.  Clinics  of  North  America, 
Nov.,  1919,  p.  801;  Losee,  A.  J.  M.  Sc.,  Nov.,  1919,  No.  5,  Vol.  CLVIII, 
p.  711. 

The  donors  must  be  healthy,  show  a  negative  Wassermann  and  prove 
to  have  a  blood  congenial  to  that  of  the  patient  (non-hemolytic). 

For  the  technique  of  these  tests  one  should  consult  hand-books  of 
laboratory  method.  (See  Hiss  and  Zinsser's  Bacteriology.) 

Theoretically,  a  parent's  blood  should  be  better  than  a  stranger's  as 
more  likely  to  represent  the  biological  characteristics,  but  this  is  by  no 
means  without  exception. 

Again,  theoretically,  a  brother's  or  sister's  blood  should  be  better 
than  the  parents',  but  at  times  it  is  absolutely  uncongenial. 

The  amounts  depend  on  age,  weight,  the  patient's  reaction,  and  the 
donor's  condition.  In  my  first  case  200  c.c.  to  300  c.c.  were  given  at 
weekly  intervals  for  five  weeks.  In  older  cases  800  c.c.  to  1,000  c.c.  may 
be  given.  If  a  good  response  is  obtained  it  is  better  to  use  the  same 
donor  than  to  change,  as  every  now  and  then  in  spite  of  satisfactory 
laboratory  tests  an  hemolysis  in  the  veins  of  the  recipient  occurs  with 
dangerous  or  disastrous  results. 

Ottenberg  and  Libman,  however,  place  implicit  reliance  in  the  results 
of  the  agglutination  and  hemolytic  test  and  say, 


768  TREATMENT  OF  ACUTE  INFECTIOUS  DISEASES 

"In  no  case  in  our  series  in  which  hemolysjs  or  agglutination  did  not 
occur  in  the  test-tube  were  any  untoward  symptoms  observed  which 
could  be  attributed  to  these  phenomena." 

Their  article  on  Blood  Transfusion  in  the  Am.  Jour.  Medical  Sciences, 
July,  1915,  is  most  illuminating. 

If  the  infecting  organism  is  known  it  is  possible  to  inoculate  a  donor 
with  vaccines  made  from  it  and  enhance  the  protective  power  of  blood 
before  he  donates. 

Human  serum  has  been  advocated  especially  by  Welch. 

See  New  York  State  Medical  Journal,  November,  1913. 

As  the  serum  contains  most  of  the  immune  bodies  an  argument  might 
be  made  for  its  selection  in  preference  to  whole  blood  and  it  certainly 
is  less  likely  to  result  in  unfortunate  accidents. 

On  the  other  hand  I  feel  that  the  whole  blood  is  more  likely  to  give 
the  maximum  benefit  than  serum  alone. 

Prophylaxis.  This  begins  with  proper  surgical  consideration  of 
foci  of  infection,  but  the  internist  must  remember  that  these  foci  may 
be  latent  in  tooth,  tonsil,  sinus  and  other  anatomical  nooks  and  corners 
and  include  all  these  in  his  routine  examination  of  patients. 

SUMMARY 

Treatment 
Rest. 

Quiet  room,   comfortable  bed,   competent  nursing,   freedom  from 
worries  and  anxieties,  exclusion  of  visitors. 

Room. 

Provide  for  light,  air,  bath-room  facilities,  approach  to  porch  or 
verandah  if  possible. 

Bed. 

Hospital  type,  half  or  three-quarters  width,  woven  wire  springs,  firm 
mattress. 

Diet. 

At  onset,  don't  push. 

Later,  provide  for  3,000  calories,  or  as  much  as  is  well  taken,  and 

for  80  grams  of  proteid. 

Milk,  buttermilk,  koumys,  matzoon,  zoolak,  junket,  ice-cream. 
Eggs,  coddled,  poached,  custard,  egg-nog,  egg  white. 
Cereals,  different  varieties  thoroughly  cooked,  used  in  broths,  various 

invalid  and  infant  foods. 
Bread,  bread  and  butter,  toast,  milk  toast,  bread  and  milk,  crackers, 

biscuit. 


SEPTICAEMIA  AND  PY^MIA  769 

Cream,  butter,  cocoa,  sugar  in  milk,  in  cereals,  in  jellies,  in  drinks. 
Give  food  every  two  or  three  hours. 

Fluids. 

Water,  plain  or  aerated,  lemonade,  orangeade,  diluted  fruit  juices. 
Imperial  drink  (1  tablespoonful  of  cream  of  tartar  to  3  pints  of  boiling 
water,  add  sugar  and  lemon  peel  to  flavor). 

Bowels. 

When  first  seen. 

Calomel  in  divided  doses,  followed  by  salts  or  salts  alone  or  castor 

oil. 
Calomel,  gr.  1/4  (0.015  Gm.),  every  quarter  hour  for  six  doses; 

follow  in  two  or  three  hours  by 
Epsom,  Rochelle,  or  Glauber's  salt  or  sodium  phosphate;  of  either 

5ss.  to  i  (15-30  Gm.),  or  milder  salines. 
Such  as  Hunyadi  water. 
Milk  of  magnesia,  5i-ii  (30-60  c.c.), 
Liquor  magnesii  citratis,  Jviii-xii  (240-360  c.c.), 
Castor  oil,  5ss.-i  (15-30  c.c.). 
or 

A  salt  or  castor  oil  without  calomel  in  same  or  double  doses. 
Later. 

Milder  salines  mentioned  above. 
Enemata. 

Care  of  the  body. 

(See  Pneumonia,  Chap.  IX,  or  Typhoid  Fever,  Chap.  XIV.) 

Local  suppurative  processes. 
Surgical  procedure. 

Symptomatic  treatment 
Fever. 

Cool  or  lukewarm  sponges. 
Hypersemia. 

Cold  sponges. 

Cold  packs. 

Cold  baths. 
Chills. 

Heat  to  feet  and  body  surface. 

Hot  drinks. 
Collapse. 

Heat  to  body  and  feet. 

Hot  drinks. 

Diffusible  stimulants. 

Stronger  water  of  ammonia  on  a  towel  held  to  nose. 

Adrenalin  (1:1000)  m.  x  to  m.  xv  (0.65-1  Gm.)  intramuscularly. 

Camphor  gr.  v  (0.30  Gm.)  in  oil,  intramuscularly. 


770  TREATMENT  OF  ACUTE  INFECTIOUS  DISEASES 

Caffeine  sodium  benzoate  or  sodium  saliqylate  gr.  v  (0.30  Gm.)  in 
water  intramuscularly. 

Strophanthin,  gr.  1/120  to  gr.  1/90  (1/2-3/4  mg.)  intravenously  or 

intramuscularly. 
Vomiting. 

Cracked  ice. 

Mustard  paste  1  in  2,  3  or  4  to  epigastrium. 

Cut  down  on  diet,  and  fats  and  sugars  in  diet. 

Lavage  and  gavage. 

Rectal  feeding. 
Nervous  symptoms. 

Delirium. 
Fresh  air. 

Cold  sponges  or  packs. 
Abundance  of  water. 
Ice-bag  to  the  head. 
Never  leave  patient  alone. 
Restraint  in  mild  delirium. 

Bromides,  gr.  xv  to  gr.  xxx  (1-2  Gm.). 

Codeine  phosphate,  gr.  1/4  (0.015  Gm.)  hypodermically. 

Morphine  sulphate,  gr.  1/8  to  gr.  1/4  (0.008-0.015  Gm.)  hypodermic- 
ally. 

Hyoscine  hydrobromide  gr.  1/200  to  gr.  1/100  (0.0003-0.0006  Gm.) 

hypodermically. 
Insomnia. 

Bromides,  gr.  xv  to  gr.  xxx  (1-2  Gm.). 

Trional,  gr.  xv  (1  Gm.).  Repeat  in  two  or  three  hours  if  neces- 
sary. 

Chloral  amid,  gr.  xxx  (2  Gm.).  Repeat  in  two  or  three  hours  if 
necessary. 

Codeine  phosphate,  gr.  1/8  to  gr.  1/4  (0.008-0.015  Gm.)  hypoder- 
mically. 

Morphine  sulphate  in  persistent  cases,  gr.  1/8  to  gr.  1/4  (0.008-0.015 

Gm.)  hypodermically. 
Headaches. 

Ice-bag  or  ice-coil. 

Morphine  gr.  1/8  to  gr.  1/4  (0.008-0.015  Gm.)  in  severe  cases. 
Convulsions. 

Morphine  sulphate,  gr.  1/4  (0.015  Gm.)  hypodermically. 

(See  Scarlet  Fever,  Chap.  XVII.) 
Circulation. 

Digitalis  m.  xxx  of  the  tincture  (2  c.c.)  or  gss.  (15  c.c.)  of  the  in- 
fusion or  gr.  iii  (0.2  Gm.)  of  the  leaf  three  or  four  times  a  day. 

Strophanthin  in  emergency,  gr.  1/90  to  gr.  1/60  (0.00075-0.001 
Gm.)  intravenously  or  intramuscularly  and  repeat  in  six  to 
twelve  hours  if  needed. 

(See  Pneumonia,  Chap.  IX.) 

Accidents  of  the  disease. 
Endocarditis. 
Meningitis. 


SEPTICAEMIA  AND  PYAEMIA  771 

(See  Cerebro-spinal  Meningitis,  Chap.  XXV.) 
Thrombophlebitis. 
Rest. 

Elevation  of  extremity  affected. 
Application  of  heat,  fomentations. 
Protection  with  cotton  batten. 
Embolism — infarcts. 
Of  the  lung. 

(See  Pneumonia,  Chap.  IX.) 
Of  the  spleen. 
For  pain. 

Local  application  of  heat. 

Morphine  sulphate,   gr.   1/8  to  gr.   1/4   (0.008-0.015   Gm.) 

hypodermically. 
Arthritis. 

(See  Rheumatic  Fever,  Chap.  III.) 
If  joints  suppurate,  evacuate. 
Muscles,  abscesses,  incise. 
Kidneys. 

Infarcts— expectant  treatment. 
Nephritis. 
(See  Scarlet  Fever,  Chap.  XVII.) 

Specific  treatment 

Bacillus  diphtheria*  septicaemia. 
Diphtheritic  antitoxin. 
Large  doses  intravenously. 
(See  severest  cases,  Diphtheria,  Chap.  XVIII.) 
Scarlet  fever. 

Polyvalent  streptococcic  sera. 
(See  text.) 
Vaccine  therapy. 

(See  text.) 
Puerperal  sepsis. 

(See  text.) 
Staphylococcus  septicaemia. 

lactines.    }  <See  text') 
Pneumococcus  septicaemia. 
(See  text.) 
Transfusion  of  blood. 

(See  text.) 
Use  of  human  serum. 

(See  text.) 
Prophylaxis. 


CHAPTER  XLVI 

ERYSIPELAS 

ERYSIPELAS  is  a  disease,  deriving  its  name  from  its  chief  clinical 
characteristic,  a  redness  of  the  skin  due  to  an  inflammation  of  this 
structure,  resulting  from  an  invasion  by  the  streptococcus  pyogenes, 
sometimes  called  streptococcus  erysipelatis  of  Fehleisen. 

Morphologically  and  culturally  there  is  no  difference  between  strep- 
tococcus pyogenes  and  streptococcus  erysipelatis,  but  it  is  probable 
that  the  affinity  of  the  organism  for  the  skin  is  determined  by  some 
biological  differences  and  these  biological  differences  constituting  strains, 
and,  by  mutations,  varieties  and  species,  affords  one  of  the  most  in- 
teresting studies  of  the  present  moment. 

Not  only  is  the  skin  involved  but  in  rarer  instances  the  mucous 
membranes.  The  manner  of  skin  involvement  is  a  very  definite  one 
and  entirely  different  from  a  lymphangitis  or  cellulitis  although  the 
three  conditions  are  but  different  expressions  of  the  invasion  of  the  skin 
by  the  streptococcus  pyogenes.  The  intensity  of  the  inflammation 
varies,  too,  from  the  usual  brawny  indurated  area  of  erythema,  to 
vesiculation,  pustulation,  suppuration  and  necrosis.  Any  trauma, 
however  trivial,  and  sometimes  too  slight  to  be  detected,  affords  the 
portal  of  entry.  Again,  that  something  so  difficult  of  definition,  which 
we  call  susceptibility  and  affinity  determine  certain  sites  of  election  in  the 
skin.  By  far  the  most  common  site  of  the  infection  is  the  skin  of  the  face 
(facial  erysipelas)  constituting  88  per  cent,  of  the  whole;  the  next  most 
common  site  is  the  leg.  In  infants  it  usually  begins  about  the  umbilicus. 
As  a  rule  it  is  confined  to  the  part  first  affected,  but  may  pass  from  site 
to  site  over  the  whole  body  and  is  spoken  of  as  migrating  erysipelas. 

Infections  after  trauma,  after  operation  and  in  parturient  women 
constitute  another  class. 

The  symptoms  are  those  attributable  to  streptococcus  toxins,  in  any 
case  of  acute  infection  by  these  organisms;  after  an  incubation  of  three 
to  ten  days  there  is  a  sudden  invasion  with  chilly  sensations  or  a  distinct 
chill,  a  rapid  rise  of  temperature,  malaise,  headache,  nausea  or  vomiting, 
anorexia,  etc.  The  temperature  may  run  from  102°  F.  to  104°  F.  and  be 
very  irregular,  it  may  remain  high,  104°  F.  to  106°  F.  a  few  days  and 
then  become  irregular  and  fall  by  lysis,  or  it  may  remain  high  throughout 


ERYSIPELAS  •      773 

and  fall  by  crisis  like  a  pneumonia.  The  duration  of  the  attack  is  one  to 
two  weeks. 

The  local  symptoms  are  those  of  a  slowly  advancing  deep  scarlet, 
brawny  indurated  area  of  inflammation  with  a  clear-cut  border  as  a  rule. 
It  may  advance  up  or  down  a  limb  and  has  no  respect  for  direction  of 
lymphatic  flow.  The  skin  is  hot,  tense,  burning. 

In  facial  erysipelas  the  usual  site  of  entry  is  the  mucous  membrane 
of  the  nose  and  the  skin  over  the  nose  is  first  affected.  Out  on  either 
side,  shaped  like  a  butterfly,  spreads  the  expanding  area  of  inflamma- 
tion, until  the  whole  face,  eyes,  ears  and  scalp  are  involved.  As  it 
recedes  the  swelling  diminishes  and  the  skin  looks  dry  and  burned. 

TREATMENT 

Isolation.  Opinions  differ  about  the  necessity  for  isolation.  The 
spread  in  a  ward,  in  a  family  and  among  attendants  is  relatively  rare, 
so  rare  as  to  make  the  strict  rules  of  quarantine  observed  in  such  dis- 
eases as  small  pox,  scarlet  fever  and  diphtheria  unnecessary  if  not 
unjustifiable;  but  willing  to  be  charged  with  an  ultra  conservatism,  I 
prefer  to  isolate  the  patient  in  a  separate  room  in  a  hospital  or  in  a  house, 
forbidding  visitors  and  having  a  special  nurse  or  member  of  the  family, 
who  shall  be  instructed  to  burn  dressings,  properly  sterilize  her  hands 
after  contact  with  the  patient  and  change  her  clothes  before  mingling 
with  the  family  or  others.  The  physician  has  but  to  remember  that  his 
hands  and  instruments  are  the  means  of  conveyance  of  infection  and  he 
should  therefore  wear  rubber  gloves  in  dressing  the  lesions.  Double 
precaution  must  be  taken  by  a  surgeon  and  by  the  obstetrician. 

Room.  The  room  chosen  should  be  light  and  well  ventilated  and 
as  remote  from  the  rest  of  the  household  as  possible  while  fulfilling 
these  requirements. 

The  facilities  of  an  adjacent  bathroom  are  desirable  and  access  to  a 
verandah,  porch  or  balcony  a  valuable  adjuvant  to  the  patient's  com- 
fort and  welfare. 

An  open  hearth  affords  the  best  means  of  disposing  of  infected  dress- 
ings. 

Bed.  The  hospital  type  is  preferred,  a  half  or  three-quarter  iron  bed- 
stead with  woven  wire  springs  and  a  firm  mattress.  For  technique  of 
bed-making,  see  Pneumonia,  Chap.  IV. 

Diet.  During  the  early  hours  anorexia  forbids  forcing  the  food. 
The  swollen  condition  of  the  face  adds  to  the  difficulty  of  eating  and, 
of  course,  when,  in  the  rare  case,  the  pharynx  is  involved,  the  difficulty 
is  greatly  enhanced.  When  food  can  be  entertained  an  effort  must  be 


774  TREATMENT  OF  ACUTE  INFECTIOUS  DISEASES 

made  to  meet  the  theoretical  requirements  (see^Chap.  II).  This  is  the 
more  imperative  in  the  long  continued  cases,'  more  particularly  the 
migrating  forms. 

Water  and  drinks  made  from  fruit  juices  should  be  administered 
freely. 

Care  of  the  Body.  A  sponge  bath  with  soap  and  warm  water 
should  be  given  daily.  The  mouth  should  receive  special  attention. 
(For  details,  see  Chap.  IV.) 

The  eyes  should  be  carefully  cleansed  with  boric  acid  solution  2  per 
cent,  to  4  per  cent.,  and  as  in  the  facial  form  the  eyelids  may  be  greatly 
swollen,  especial  care  must  be  given  to  this  part  of  the  toilet;  cold  cloths 
wet  with  boric  acid  solution  may  be  applied  to  the  swollen  lids  with 
comfort  to  the  patient. 

A  cathartic  should  be  given  when  the  patient  is  first  seen.  Epsom 
salt  (magnesium  sulphate),  Rochelle  salt  (sodium  potassium  tartrate) 
or  Glauber's  salt  (sodium  sulphate)  may  be  given  in  doses  of  3ss.-i  (15- 
30  Gm.)  in  three-quarters  of  a  glass  of  water. 

One  may  precede  this  by  fractional  doses  of  calomel  gr.  1/10  to  gr. 
1/4  (0.006-0.015  Gm.)  every  ten  to  fifteen  minutes  until  gr.  i  to  gr.  iss. 
(0.060-0.10  Gm.)  are  taken;  the  salt  following  in  two  to  three  hours. 
The  smaller  doses  are  especially  indicated  if  there  is  nausea,  as  they 
are  credited  with  being  antiemetic.  Later  one  may  rely  on  milder 
salines,  such  as  liquor  magnesii  citratis  5  viii  (240  c.c.),  milk  of  magnesia 
5ii  (60  c.c.),  a  Seidlitz  powder  or  Hunyadi  water  to  keep  the  bowels  open; 
or  enemata  may  be  given  in  preference. 

Treatment  of  Symptoms.  Prodromal  symptoms  of  malaise,  loss 
of  appetite,  headache  and  a  little  temperature  require  no  consideration. 
At  the  onset  the  discomforts  of  a  high  temperature  may  be  relieved  by 
cool  sponges  and,  in  very  high  fever  or  long  sustained,  cold  baths  may 
be  used,  much  as  in  Typhoid  Fever. 

Headache  may  be  relieved  by  the  ice-bag,  by  small  doses  of  phenacetin 
gr.  iii  (0.20  Gm.)  every  hour  for  three  to  four  doses  or  acetanilid  gr. 
iss.  (0.10  Gm.)  at  the  same  intervals.  Later  on  coal-tar  derivatives 
should  not  be  used. 

Nervousness  and  sleeplessness  may  be  met  by  bromides  in  doses 
of  gr.  xv  to  gr.  xxx  (1-2  Gm.)  or  chloralamid  gr.  xx  to  gr.  xxx  (1.30-2 
Gm.)  given  in  the  early  evening  and  repeated  if  needed  late  in  the 
evening. 

If  there  is  delirium,  morphine  sulphate  hypodermically  in  doses 
of  gr.  1/8  to  gr.  1/4  (0.008-0.015  Gm.)  is  indicated  or  in  the  sthenic 
period  hyoscine  hydrobromide  gr.  1/200  to  gr.  1/100  (0.0003-0.0006 
Gm.)  hypodermically. 


ERYSIPELAS  775 

If  there  are  evidences  of  circulatory  failure  support  must  be  offered 
in  the  same  way  as  in  Pneumonia.  (See  Chap.  IX.) 

LOCAL  TREATMENT 

Facial  Erysipelas.  Many  measures  and  applications  have  been 
advocated.  To  enumerate  them  would  be  only  to  confuse  and  in  no 
way  to  edify  or  help.  I  will  mention  only  those  that  seem  to  me  to  have 
value.  My  personal  preference  has  heretofore  been  for  ichthyol  which 
I  have  used  in  25  per  cent,  to  50  per  cent,  ointment  or  painted  on  pure, 
applied  after  carefully  washing  the  face  with  soap  and  warm  water,  but 
the  face  is  more  likely  to  be  dry  and  uncomfortable  under  the  pure 
ichthyol.  Over  this  one  applies  gauze,  and  a  roughly  made  mask  with 
tapes,  to  keep  it  in  place,  may  be  applied  over  all.  The  advance  of  the 
lesion  has  been  thought  to  have  been  modified  by  compression  of  the 
healthy  skin  adjacent.  The  most  common  way  of  effecting  this  is  by 
the  application  of  collodion.  This  I  have  done  with  most  of  my  cases  in 
combination  with  the  ichthyol  treatment,  sometimes  feeling  that  I  had 
effected  something,  again  seeing  no  progress  whatever.  The  experience 
of  Inata  and  Woodyatt  at  Camp  Cody  during  the  war  would  seem  to 
accentuate  the  value  of  this  effort  to  limit  the  spread  by  the  use  of  collo- 
dion (U.  S.  P.)  applied  to  the  skin  within  half  an  inch  to  an  inch  in  ad- 
vance of  the  line  of  induration.  The  application  must  be  thorough, 
leaving  no  break  by  which  the  lesion  may  spread,  repainting  if  such 
occurs.  They  combine  this  treatment  with  the  application  to  the  area 
affected  of  a  cloth  wet  with  a  cold  saturated  solution  of  magnesium 
sulphate. 

My  own  belief  is  that  it  is  not  easy  to  convince  oneself  of  the  useful- 
ness of  any  local  measure  in  a  self-limited  disease,  running  so  short  a 
course  and  having  so  low  a  mortality  as  facial  erysipelas. 

Erdman  gave  the  average  duration  of  500  facial  cases  at  Bellevue 
Hospital  as  between  six  and  seven  days  and  the  mortality  as  5.38  per 
cent. 

Objections  to  the  ichthyol  are  its  odor,  its  appearance  and  the  be- 
smearing of  everything  about  the  patient.  The  substance  is  easily 
removed,  however,  from  the  skin  or  from  fabrics  by  soap  and  water. 
Vaseline  alone  affords  a  certain  degree  of  comfort. 

Erdman  with  his  large  experience  is  convinced  that  nothing  local 
is  better  than  simple  wet  dressings.  He  uses  boric  acid  solutions,  keep- 
ing the  solutions  cold  with  ice  and  applies  frequently  to  the  face  gauze 
dressings  dipped  in  them. 

Powders.    Bland  powders  such  as  zinc  oxide,  starch,  boric  acid  or  a 


776  TREATMENT  OF  ACUTE  INFECTIOUS  DISEASES 

combination  ©f  them,  equal  parts,  dusted  oa  the  skin  liberally  and 
covered  with  a  light  dressing  of  non-absorbent  cotton  relieves  some  of 
the  disagreeable  sensations. 

Erysipelas  of  the  extremities  runs  a  little  longer  course  than  the 
facial  cases.  Erdman's  thirty-three  leg  cases  averaged  10.88  days  with 
a  decidedly  higher  mortality  (27.37),  than  the  facial  cases  (5.38  per 
cent.) . 

Ichthyol  is  to  be  used  in  the  same  manner  as  in  facial  cases. 

A  very  excellent  treatment  of  these  cases  is  the  wet  dressing,  especially 
that  of  aluminum  acetate.1  Boric  acid  solutions  are  also  suitable  for 
these  cases,  but  I  fail  to  see  any  advantage  in  the  use  of  the  stronger 
antiseptics,  such  as  bichloride  of  mercury. 

Migratory  Erysipelas.  This  is  a  very  severe  form  of  the  disease, 
both  because  of  the  extent  of  the  body  involved  and  because  it  includes 
so  many  of  the  infant  cases. 

The  mortality  in  Erdman's  fifty-six  cases  was  50  per  cent.  The 
duration  averaged  14.44  days. 

Ichthyol  and  the  wet  dressings,  may  be  used  in  these  cases,  so  far 
as  the  extent  of  the  lesion  makes  these  measures  practical. 

Erysipelas  in  Infants.  Some  8  per  cent,  of  the  cases  of  erysipelas 
occur  in  infants  under  two  years  of  age.  The  affection  is  far  more  serious 
than  in  adult  life.  New-borns  are  especially  liable  to  the  disease.  The 
portal  of  entry  is  the  umbilical  cord.  The  type  is  migrating;  death 
usually  occurs  at  the  end  of  six  to  ten  days.  Complications  are  likely  to 
occur. 

Treatment  begins  with  prophylaxis  and  the  proper  care  of  cord, 
buttocks  and  vulva. 

The  treatment  consists  in  the  use  of  ichthyol,  wet  dressings,  vaseline 
and  powders  as  in  adult  cases  detailed  above.  The  mortality  of  in- 
fants under  two  years  averages  about  40  per  cent. 

From  two  years  to  sixteen  years  children  are  singularly  free  from  the 
infection  (about  1  per  cent.). 

Specific  Treatment.  Drug  specifics  in  disease  have  become  in 
these  days  of  searching  criticism  a  woefully  depleted  company.  Among 
those  to  deserve  banishment  from  the  category  are  iron  and  quinine  in 
erysipelas.  I  can  see  no  good,  whatsoever,  from  their  use,  but  some 
disadvantages,  such  as  gastric  irritation. 

Vaccines.  One  is  loath  to  abandon  the  hope  held  out  by  the  use 
of  vaccines  in  erysipelas  and  yet  the  most  extensive  series  of  cases 

1  Formula  Aluminis 3i  ss.      (6 . 00) 

Plumbi  acetatis 5i  ss.     (45.00) 

Aq.  q.  s.  ad Oij      (1000.00) 


ERYSIPELAS  777 

(ninety-five)  of  which  I  am  cognizant  conducted  by  clinicians  and 
bacteriologists  with  whom  I  am  personally  acquainted  and  for  whose 
work  I  have  the  highest  regard  leads  to  these  conclusions. 

"From  our  experience  with  vaccines  in  erysipelas  I  must  state  that 
the  duration  of  the  disease  was  not  at  all  lessened,  the  mortality  re- 
mained at  the  same  level,  and  there  was  no  immunity  guaranteed  against 
recurrence,  against  spreading  of  the  lesion,  nor  were  complications,  such 
as  cellulitis  and  abscesses  prevented;  from  the  statements  furnished 
by  the  patient,  moreover,  I  could  not  gather  that  there  was  any  ameliora- 
tion of  the  subjective  symptoms."  (Erdman,  J.  A.  M.  A.,  December  6, 
1913.) 

Transfusion  of  Blood.  In  severe  cases  I  should  consider  the  problem 
as  one  of  septicaemia  and  hold  the  same  attitude  towards  the  measure 
as  in  that  condition.  (See  Septicaemia,  Chap.  XXXIV.) 

Complications.  Many  of  these  are  surgical  and  to  be  treated  on 
surgical  principles;  phlegmon,  gangrene,  abscesses,  otitis  media,  edema  of 
the  larynx,  periostitis,  purulent  arthritis,  suppurative  adenitis,  sinusitis. 

Others  are  medical  such  as  Pneumonia  and  Pleurisy  (see  Chaps. 
IX  and  VIII),  Acute  Nephritis  (see  Scarlet  Fever,  Chap.  XVII),  Bron- 
chitis, Tonsillitis,  Arthritis  (see  Chaps.  Ill,  V  and  VII),  Endocarditis, 
Septicaemia  and  Pyaemia  (see  Chap.  XLV).  Most  important  among 
these  as  a  cause  of  death  are  Septicaemia  and  Pneumonia. 

Immunity  seems  difficult  to  establish  and  the  same  individual  is 
prone  to  suffer  from  the  disease  again  and  again.  Moreover,  relapses 
are  of  common  occurrence. 

Prophylaxis.  Proper  attention  should  be  given  to  lesser  traumata 
that  furnish  the  portal  of  entry,  and  particularly  in  those  individuals 
who  have  already  suffered  from  the  disease. 

Such  slight  traumatisms  may  be  looked  for  in  the  nasal  mucosa 
and  in  the  skin  about  the  nose,  ear  and  elsewhere  about  the  face. 

A  vaccination  wound  may  be  the  site  of  infection,  or  an  old  ulcer 
of  the  leg.  In  infants  it  is  commonly  the  navel,  excoriated  buttocks  or 
vulva.  Again  operative  wounds  may  be  infected  and  every  care  should 
be  exercised  by  the  obstetrician  to  avoid  contact  with  erysipelas. 

It  is  a  wise  precaution  to  disinfect  a  patient's  clothes  before  his  dis- 
charge from  the  sick-room. 


778  TREATMENT  OF  ACUTE  INFECTIOUS  DISEASES 

SUMMARY 

Isolation. 

Safer  to  isolate. 

Room. 

Light  and  well  ventilated. 

Remote  from  noise  of  household. 

Near  bathroom. 

Accessible,  if  possible,  to  veranda  or  porch. 

Open  hearth  desirable. 

Bed. 

Hospital  type;  one-half  or  three-quarters  iron  bedstead. 

Woven  wire  springs;  firm  mattress. 

(For  technique  of  bed-making,  see  Pneumonia,  Chap.  IX.) 

Diet. 

Early  hours;  don't  force. 

Prolonged  cases.    (See  Chap.  II  or  Chap.  IX.) 

Water,  lemonade,  orangeade,  alkaline  and  aerated  waters  freely. 

Care  of  the  body. 

(For  details,  see  Pneumonia,  Chap.  IX.) 

Eyes,  2  per  cent,  to  4  per  cent,  boric  acid  solutions. 

Cold  compresses  to  swollen  lids. 

Bowels. 

Rochelle,  Epsom  or  Glauber's  salt,  5ss.  to  5i  (15-30  Gm.), 
or 

Calomel,  gr.  1/10  to  gr.  1/4  (0.006-0.15  Gm.),  every  ten  to  fifteen 
minutes  until  gr.  i  to  gr.  iss.  are  taken,  followed  in  two  or  three 
hours  by  salts  in  doses  named  above. 
Later. 

Milder  salines. 

Liquor  magnesii  citratis,  5viii  (240  c.c.). 
Milk  of  magnesia,  §ii  (60  c.c.). 
Seidlitz  powder. 
Hunyadi  water. 
Enemata. 

Treatment  of  symptoms. 
Fever. 

If  high,  cool  sponges. 
Headache. 

Ice-bag  to  head. 

Phenacetin,  gr.  iii  (0.20  Gm.)  every  hour  for  three  to  four  doses, 

in  early  stages. 

Acetanilid,  gr.  iss.  (0.10  Gm.)  at  the  same  intervals,  in  early  stages. 
Nervousness. 


ERYSIPELAS  779 

Bromides,  gr.  xv  to  gr.  xxx  (1-2  Gm.),  either  potassium  or  mixed 

bromides. 
Insomnia. 

Chloralamid,  gr.  xx  to  gr.  xxx  (1.30-2  Gm.), 

or 

Trional,  gr.  x  to  gr.  xv  (0.60-1  Gm.),  in  early  evening  and  repeat 

if  needed. 
Delirium. 

Morphine  sulphate,  gr.  1/3  to  gr.  1/4  (0.008-0.015  Gm.),  hypoder- 

mically. 
Hyoscine  hydrobromide,  gr.   1/200  to  gr.  1/150  (0.0003-0.00045 

Gm.),  hypodermically,  only  in  sthenic  stage. 
Circulation. 

(See  Pneumonia,  Chap.  IX.) 

Local  treatment:  use  of  rubber  gloves. 
Facial  erysipelas. 

Paint  margin  of  advancing  lesion  with  collodion.    (See  text.) 
Apply  to  area  affected  25  to  50  per  cent,  ichthyol  or  cold  saturated 

solution  of  magnesium  sulphate;  vaseline. 
Wet  dressings  of  boric  acid  2  per  cent,  to  4  per  cent.    Solutions 

kept  cold  with  ice. 

Powders.    Zinc  oxide,  boric  acid  and  starch  equal  parts. 
Erysipelas  of  the  extremities. 
Ichthyol:  may  be  combined  with  the  application  of  collodion. 

(See  text.) 

Twenty-five  per  cent,  to  50  per  cent,  or  pure  ichthyol. 
Wet  dressings. 

Aluminum  acetate. 
Boric  acid  solutions. 
Migratory  erysipelas. 
Ichthyol. 
Wet  dressings. 
Erysipelas  in  infants. 
Prophylaxis. 

Care  of  cord  or  excoriated  buttocks  or  vulva. 

Ichthyol. 

Wet  dressings. 

Powders. 

Vaseline. 

Specific  treatment. 
(See  text.) 

Vaccines,  very  little  value. 
Transfusion  of  blood. 

(See  Septicaemia,  Chap.  XLV.) 

Complications. 
Phlegmon,  gangrene,  abscesses,  otitis  media,  edema  of  the  larynx, 

periostitis,  purulent  arthritis,  suppurative  adenitis,  sinusitis. 
Treat  on  surgical  principles. 


780  TREATMENT  OF  ACUTE  INFECTIOUS  DISEASES 

Pneumonia  and  Pleurisy.    (See  Chaps.  IX  and  VIII.) 
Acute  nephritis.    (See  under  Scarlet  Fever,  Ghap.  XVII.) 
Bronchitis,  tonsillitis,  arthritis.    (See  Chaps.  Ill,  V,  VII.) 
Endocarditis,  septicaemia  and  pyaemia.    (See  Chap.  XLV.)     - 

Prophylaxis. 

Attention  to  slight  traumata  about  nose,  ears,  face;  to  old  ulcers;  to 
cord,  buttocks  and  vulva  in  infants. 

Disinfection. 
Patient's  clothes  should  be  disinfected. 


INDEX 


Abdomen,  protection  of,  in  bacillary  dysentery, 

358 
Abdominal  muscles,  paralysis  of,  in  poliomyelitis, 

600 

Abdominal  support  in  pertussis,  526,  533 
Abortive  poliomyelitis,  591 
Abscess,  liver,  in  amebic  dysentery,  377,  378,  379 

lung,  in  epidemic  influenza,  254 

retropharyngeal  differentiated  from  diphtheria, 

464 

Abt,  on  diarrhea  in  infants,  360 
Acetanilid,  221 

chemistry  of,  221 

in  bronchitis,  103,  109 

in  epidemic  influenza,  244 

in  erysipelas,  774 

in  grip,  218,  231 

in  Malta  fever,  659 

in  mumps.  547 

in  pleurisy,  118,  126 

in  poliomyelitis,  596,  605 

in  rheumatism,  45 

in  rhinitis,  72,  76 

in  small  pox,  614 

in  tonsillitis,  83,  89 

in  trench  fever,  752,  754 

toxic  effects  of,  223 

Acetphenetidin,  45,  66,  and  see  Phenacetin 
Acetylsalicylic  acid,  42,  and  see  Aspirin 
Acidosis,  46 

from  salicylates,  46 

in  epidemic  influenza,  251,  267 

in  rheumatism,  46 
Aconite  in  febrile  conditions,  6 

in  tonsillitis,  83,  89 
Adenitis  in  diphtheria,  473 

in  glandular  fever,  556,  558 

in  measles,  499,  509 

in  scarlet  fever,  412,  437 

in  tonsillitis,  86 
Adenoids,  80 

attention  to  in  bronchitis  of  children,  108,  111 

removal  of  in  prophylaxis  of  pneumonia,  193 
in  rheumatism,  62 
in  whooping  cough,  537 

Adrenalin,  in  asthmatic  attacks  in  bronchitis  of 
children,  108,  111 

in  bacillary  dysentery,  365,  373 

in  coryza,  73 

in  diphtheria,  467,  482 

in  epidemic  influenza,  243,  245,  248,  249,  267 

in  pertussis,  534,  542 

in  pneumonia,  144,  145,  177,  178,  204,  248 

in  rhinitis,  73,  74,  77,  78 

in  scarlet  fever,  401,  406,  435 

in  sinus  involvement  of  grip,  228,  233 
Age,  calorie  requirements  and,  12 

in  relation  to  rheumatism,  30 
Agglutination  method,  in  pneumonia,  130 
Agramonte,  food  formula  in  yellow  fever,  737 
Air  cushions  for  patient  in  bacillary  dysentery, 

357 
Albuminuria  complicating  measles,  501 

from  salicylates,  40 

in  diphtheria,  473 

in  malaria,  336 

in  scarlet  fever,  414 
Alcohol,  in  diphtheria,  471 

in  malaria,  343 

in  scarlet  fever,  401 

in  typhoid  fever,  299 

Alcohol  sprays,  for  itching,  in  small  pox,  612 
Algid  malaria,  336,  349 


Alimentary  canal,  care  of,  see  under  the  several 


Alkaline  salts,  as  diuretics  in  scarlatinal  nephritis, 

420 

Alkaline  treatment  for  rheumatism,  46 
Alkaline  waters,  in  yellow  fever,  738 
Allergic  following  revaccination  for  small  pox,  619 
Amberg  and  Rowntree,  on  creatinin,  23 
Amebic  dysentery,  374 

appendicostomy  in,  383,  386 

bed  in.  355,  357,  370,  375 

care  of  body  in,  356,  370,  375 
of  bowels  in,  359,  371,  376,  384 

carriers  of,  382,  386 

complications  of,  382 

diet  in.  358,  368,  371,  374 

emetine  treatment  of,  376,  384 

empirical  treatment  of,  375 

entamoaba  coli  in,  374 
histolytica  in,  374 

hepatitis  in,  377,  378,  379,  385 

ipecac  in,  376,  384 

pathology  of,  375 

prophylaxis  of,  383,  386 

quinine  treatment  of,  381,  385 

relapses  in,  380,  385 

rest  in.  354,  370,  375 

room  in,  356,  370,  375 

sequel®  of,  382 

specific  organism  of,  374,  384 

summary  of  treatment  of,  383 

surgery  in,  383,  386 

symptomatic  treatment  of,  386 

symptomatology  of,  375 
Amido-bodies,  24,  34 

Ammonia,  for  prevention  of  collapse  in  malaria, 
325 

for  prevention  of  collapse  in  pneumonia,  177 

for  prevention  of  collapse  in  septicemia,  760 
Ammonium  salts,  in  pneumonia,  166 
Anaphylactic  reaction  in  pneumonia,   134,    145, 

Anderson  on  yellow  fever,  738 
Anemia  following  diphtheria,  474,  485 

following  typhoid  fever,  319 

in  malaria.  337,  351 

in  rheumatism,  57,  68 

in  scarlet  fever,  423 
Anesthetic  for  lumbar  puncture  in  cerebrospinal 

meningitis,  570 
Angina,  in  diphtheria,  465 

in  scarlet  fever,  398,  432 

Vincent's,  91,  and  see  Vincent's  angina 
Anthrax,  678 

aim  of  treatment,  679 

bed  in.  682,  685 

care  of  body  in,  683,  685 

cauterization  of  pustule,  679 

circulation  in,  683,  685 

conveyance  of,  678 

convulsions  in,  684 

delirium  in,  684,  686 

diarrhea  in,  684,  686 

diet  in,  683 

disposal  of  discharges,  secretions,  etc.,  in,  683 

excision  of  pustule  in,  679,  680 

expectant  treatment  in,  680 

headache  in,  683,  685 

intestinal,  679 

isolation  in,  682 

lesion  of,  678 

local  treatment  of,  679,  684 

organism  of,  678 


782 


INDEX 


Anthrax,  prophylaxis  of,  684,  686 
rest  in,  682 

restlessness  in,  663,  685 
room  in,  682,  685 
sleeplessness  in,  683,  685 
specific  treatment  of,  681,  682,  684 
summary  of  treatment  of,  684 
supportive  treatment  of,  682 
symptomatic  treatment  of,  683 
vomiting  in,  683,  685 
Anti-anthrax  serum,  681 
Antifebrin.    See  Acetanilid. 
Anti-lepral,  672 
Anti-plague  serum,  636 
Anti-pneumonic  serum,  132,  133 
Antirabic  treatment,  703 
Antipyretics, 

chemistry  of,  221 
in  febrile  conditions,  6,  7,  9 
toxic  effects  of,  223 
Antipyrin,  in  bronchitis,  109 
in  coryza,  72,  73 
in  fibrinous  pleurisy,  118,  126 
in  influenza,  218,  231,  245 
in  laryngitis,  98,  100 
in  measles,  498 
in  pertussis,  529,  540 
in  rheumatism,  45 
in  rhinitis,  72,  73,  74,  76,  77,  78 
in  tonsillitis,  83,  89 
in  trench  fever,  752,  754 
Antiseptics,  in  treatment  of  wounds,  722 
Antitoxemic  treatment  of  fever,  1 
Antitoxin,  administration  of,  458,  480 
in  cerebrospinal  meningitis,  567,  573 
diphtheria,  454 

death  following  use  of,  459 
disagreeable  results  of,  458 
dosage  of,  454,  457,  479 
early  administration  of,  457 
evidences  of  improvement  due  to,  458 
immunizing  dose  of,  460,  481 
precautions  in  use  of,  481 
preparation  of,  454 
unit  of,  454 

for  hemorrhage  of  typhoid  fever,  296 
for  laryngeal  diphtheria,  461,  481 
for  laryngitis  complicating  measles,  498,  508 
in  pneumonia,  130 
paralysis  prevented  by,  471 
tetanus,  715,  722,  725,  727,  and  see  Tetanus 

antitoxin 
Antitoxins,  453 
Antitussin,  in  pertussis,  532 
Antrum,  involvement  of,  in  coryza,  75 
in  influenza,  228,  233 
in  rhinitis,  75,  79,  and  see  Sinusitis 
Apathy  in  encephalitis  lethargica,  271 
Aphthse  epizooticae,  693,  and  see  Foot  and  mouth 

disease 

Apparatus  for  paralysis  in  poliomyelitis,  602 
Appendicostomy     in     amebic    dysentery,     383, 

386 

Appetite,  11 
Appetit-saft,  34 

Apple,  baked,  food  value  of,  17 
Argyrol,  in  coryza,  73 

in  rhinitis,  73,  77 

Arsenic,  for  anemia  in  malaria,  339,  340 
for  convalescence  from  Malta  fever,  660 
in  chorea,  60 

in  malarial  cachexia,  339 
substitute  for  quinine,  340 
Arthritis  in  erysipelas,  340 
in  mumps,  551 
in  pneumonia,    191 
in  rheumatism,  51 
in  scarlet  fever,  413,  417 
in  septicemia,  763,  771 
Ascites,  in  scarlatinal  nephritis,  415,  421 
Ashburn  and  Craig,  on  dengue,  641 
Ashurst     and     John,     on     tetanus,     711,     714, 

717 
Asiatic  cholera,   646,  and  see  Cholera,  Asiatic 


Aspiration,  in  pleurisy  with  effusion,  120,  127 
in  pleurisy  and  empyema  in  epidemic  influenza, 

technique  of,   120 
Aspirin,  constitution  of,  60 

m  bronchitis,  104,  109 

in  chorea,  60 

in  coryza,  72 

in  encephalitis  lethargica,  274 

in  epidemic  influenza,  245 

in  fibrinous  pleurisy,  117,  126 

in  glandular  fever,  556 

in  Malta  fever,  659 

in  pneumonia,  145 

in  rheumatism,  42 

in  rhinitis,  72,  76 

in  scarlatinal  arthritis,  413 

in  tonsillitis,  83,  89 

in  trench  fever,  752,  754 

toxic  dose  of,  43 
Assimilation  in  acute  infectious  diseases,  18 

efficiency  of  processes  of,  3 
Asthma,  after  administration  of  serum,  145 
Astringents  in  diarrhea  of  bacillary  dysentery,  364 
Atropine,  in  Asiatic  cholera,  648 

in  asthma,  after  administration  of  serum  in 
pneumonia,  145 

in  bacillary  dysentery,  365,  373 

in  diphtheria,  473 

in  lumbar  puncture,  572 

in  pertussis,  530 

in  photophobia  of  measles,  494,  501 

in  pneumonia,  144,  145,  175,  178 

in  poliomyelitis,  600 

in  pulmonary   edema  of  epidemic  influenza, 
249,  267 

in  rheumatism,  57 

in  sinus  involvement  of  influenza,  228 

in  tetanus,  720 
Auricular  fibrillation  in  epidemic  influenza,  257, 

269 

Auto-extubation,  464 
Auto-serotherapy  in  chorea,  61 

in  pleurisy  with  effusion,  124,  127 

Bacillary  dysentery,  353 

bed  in,  355,  357,  370 

care  of  body  in,  356,  370 
of  bowels  in,  359,  371 

carriers,  369 

change  of  environment  in,  368 

chronic  form  of,  366,  373 

collapse  in,  373 

diagnosis  of,  354 

diarrhea  in,  364,  372 

diet  in,  358,  368,  371,  374 

duration  of,  366 

empirical  treatment  of,  361,  371 

heart  in,  366 

nausea  in,  360 

pain  in,  362 

pathology  of,  354 

precautions  of  nurse  in,  356,  370 
of  physician  in,  356,  370 

prophylaxis  of,  369,  374 

rest  in,  354 

room  in,  356,  370 

saline  treatment  in,  359.  362,  367,  372 

serum  in,  360,  371 

specific  treatment  of,  360,  371 

subacute  form  of,  366,  373 

summary  of  treatment  of,  370 

symptomatic  treatment  of,  362,  372 

tenesmus  in,  363,  372 

therapy  of,  354 

topical  applications  in,  362,  372 

ulcers  in,  367,  373 

vaccine  therapy  in,  361,  366,  371,  373 

vomiting  in,  360 

water  in,  359 

Bacilluria  in  typhoid  fever,  300 
Backache  in  smallpox,  614 

in  yellow  fever,  738,  742 
Bacon,  food  value  of,  17 


INDEX 


783 


Bacteremia,  757 

Baking  for  paralysis  of  extremities  in  poliomye- 
litis, 601 

Barker  and  Sladen  on  infectious  jaundice,  732 
Baruch  on  hydrotherapy,  5,  84,  97,  157,  159 
Bass  on  blackwater  fever,  343 

on  malaria,  328,  329 

Bastedo  on  alkaline  salts  in  rheumatic  fever,  43 
Baths.    See  under  the  several  diseases, 
as  antipyretic  measure,  19 
Brand,  288 

in  pneumonia,  161 
in  typhoid  fever,  5,  288,  291 
mustard,  546 
Ziemssen's,  291 

Bath-water,  disinfection  of,  281,  310 
Beans,  string,  food  value  of,  17 
Bed,  see  under  the  several  diseases 
Gatch,  147 

importance  of  in  rest,  2 
technique  of  making,  279 
Bed  linen,  disinfection  of,  281 
Bed  pan,  disinfection  of,  281 
in  dysentery,  357 
in  epidemic  influenza,  243 
Bedsores,  in  cerebrospinal  meningitis,  581 

in  typhoid  fever,  280,  310 
Belladonna,  idiosyncrasy  for,  530 
in  mumps,  548,  553 
in  pertussis,  529,  540 
in  sinus  involvement  in  influenza,  228 
in  tenesmus  in  bacillary  dysentery.  363 
Belt,  abdominal,  in  pertussis,  526,  533 
Benzoin,  in  bronchitis,  105,  109 
in  glanders,  689 
in  laryngitis,  96 

in  membraneous  angina  in  scarlet  fever,  401 
in  pertussis,  527 

Benzyl  benzoate,  in  amebic  dysentery,  381,  385 
chloride,  in  leprosy,  672 

in  pertussis,  532 

Bercovitz,  on  treatment  of  leprosy,  673 
Besredka's  method  of  desensitization  in  pneu- 
monia, 136 
Bethea's  method  in  amebic  dysentery,  378 

of  giving  quinine  in  malaria,  329 
Bilious  remittent  fever,  336 
Bismuth,    for  diarrhea,   in   bacillary   dysentery, 

364,372 

in  epidemic  influenza,  246 
in  infectious  jaundice,  730 
in  plague,  636 
in  typhoid  fever,  294 

for  nausea,  in  cerebrospinal  meningitis,  565 
in  scarlet  fever,  422 
in  typhoid  fever,  295 
for  noma,  in  measles,  499 
for  retching,  in  smallpox,  615 
for  vomiting,  in  cholera,  648 
in  Malta  fever,  659 
in  scarlet  fever,  397 
in  typhoid  fever,  295 
in  amebic  dysentery,  382,  386 
in  foot  and  mouth  disease,  695 
in  infectious  jaundice,  730 
Bitter  bush,  in  treatment  of  amebic  dysentery, 

382 

Bites,  treatment  of  old.  709 
Black  vomit  of  yellow  fever,  739,  742 
Blackwater  fever,  343,  352 
prophylaxis  of,  345,  352 
summary  of  treatment,  352 
symptoms  of,  344 
treatment  of,  344,  352 

Bladder,  care  of.    See  under  the  several  diseases 
Blake,  on  typing  of  sputum,  132 
Blaud's  pill,  for  anemia,  in  diphtheria,  474,  484 
in  scarlatinal  nephritis,  423,  441 
in  trench  fever,  755 

for  convalescence  from  measles,  502,  511 
from  mumps,  551 
from  pertussis,  537 
in  glandular  fever,  557 
in  malaria,  339,  351 


Blindness,  due  to  quinine,  333 
Blisters,  application  of,  50 
in  fibrinous  pleurisy,  116,  126 
in  rheumatism,  50 
Blood,  in  amebic  dysentery,  375 
in  encephalitis  lethargica,  272 
normal  human,  in  scarlet  fever,  409 
typing  of,  in  pneumonia,  130 
Blood  pressure,  effects  of  cold  water  on,  5 

of  fresh  air  on,  4 

Blood  transfusion  in  erysipelas,  777 
in  septicemia,  766 
method  of,  766 
Bloodgood,  on  anthrax,  681 
on  rabies,  701 
on  tetanus,  713,  720 

Body,  care  of.    See  under  the  several  diseases 
Body  louse,  in  typhus  fever,  624,  626 
Body  mechanism  for  conversion  of  energy,  27 
Body  surface  and  calorie  measurement,  13 
Bordet  on  pertussis,  520 

Bowels,  care  of.     See  under  the  several  diseases 
Bradycardia,  in  epidemic  influenza,  257,  269 
Bran  bath  in  scarlet  fever,  395 
Brand  bath,  contraindications  to,  291 
in  febrile  conditions,  5 
in  pneumonia,  161 
in  typhoid  fever,  288 
method  of,  288 
Bread,  food  value  of,  17 
Break-bone  fever,  641,  and  see  Dengue 
Brill's  disease,  625 
Bromides,  for  convulsions,  in  pertussis,  536 

in  tetanus,  719 

for  delirium,  in  typhus  fever,  629,  632 
for  headache,  in  pneumonia,  170,  202 
for  insomnia,  in  cerebrospinal  meningitis,  566 
in  encephalitis  lethargica,  275 
in  epidemic  influenza,  245 
in  Malta  fever,  659 
in  pertussis,  531,  533 
in  pneumonia,  169 
in  rheumatic  fever,  37 
in  Rocky  mountain  spotted  fever,  666 
in  scarlet  fever,  407 
in  septicemia,  761 
in  smallpox,  415,  423 
in  tonsillitis,  84.  89 
in  typhoid  fever,  298,  316 
for  nervous  symptoms,  in  erysipelas,  774 
in  measles,  495,  506 
in  septicemia,  761 

for  restlessness,  in  cerebrpspinal  meningitis,  566 
in  encephalitis  lethargica,  275 
in  scarlet  fever,  407 
in  poliomyelitis,  596,  605 
per  rectum,  in  rabies,  706,  709 
Bromoform,  in  pertussis,  532 
Bronchiectasis,  in  epidemic  influenza,  255 
Bronchitis,  acute,  101 

aches  and  pains  in,  103,  109 

care  of  bowels  in,  103,  109 

children,  management  of,  107,  110 

cough  in,  102.  106,  110 

counterirritation  in,  104,  109 

cupping  in,  104,  109 

diet  in,  103,  108 

early  measures  in,  103,  109 

etiology  of,  101 

expectorants  in,  106,  107,  110 

fever  in,  102 

fomentations  in,  105,  109 

headaches  in,  103,  109 

inhalations  in,  105,  107,  109,  110 

isolation  in,  103,  108 

local  treatment  of,  104,  109 

pathplogy  of,  101 

physical  signs  of,  102 

precautions  in,  103,  108 

prophylaxis  of,  108,  111 

room  in,  102,  108 

summary  of  treatment  of,  108 

symptoms  of,  102 

vaccines  in,  108,  111 


784 


INDEX 


Bronchitis,  capillary,  101 

in  grip,  227,  233 

in  measles,  498,  008 

in  pneumonia,  164 

Bronchopneumonia,     101,     128,     179,    and    see 
Streptococcus  pneumonia 

differentiated  from  laryngeal  diphtheria,  464 

in  diphtheria,  473 

in  measles,  495,  507 

in  pertussis,  534,  542 

in  scarlet  fever,  423 

physiology  of  diet  in,  3 

specific  treatment  of,  179 
Brook,  on  quinine  treatment  of  amebic  dysentery, 

381,  385 

Brown,  on  amebic  dysentery,  376 
Brown,  Wade,  on  blackwater  fever,  343 

on  malaria,  324,  337 
Brown  mixture,  in  bronchitis,  106,  110 
Browne,  on  scarlet  fever,  400 
Bubonic  plague,  634,  and  see  Plague 
Burning  and  itching,  in  measles,  491,  505 

in  small  pox,  612,  621 
Butter,  food  value  of,  17 
Buttermilk,  food  value  of,  17 

Cachexia,  malarial,  338,  350 
Caffeine,  double  salts  of,  6,  9 

for  prostration  from  belladonna,  531 

in  anthrax,  683 

in  bronchitis,  104,  109 

in  cerebrospinal  meningitis,  566 

in  cholera,  651 

in  diphtheria,  470 

in  epidemic  influenza,  244 

in  febrile  conditions,  6,  9 

in  glanders  and  farcy,  689 

in  grip,  219 

in  malaria,  335,  349 

in  Malta  fever,  660 

iii  measles,  495 

in  pleurisy  with  effusion,  123 

in  pneumonia,  176,  178,  204,  205 

in  poliomyelitis.  600,  606 

in  scarlatinal  nephritis,  420 

in  scarlet  fever,  405,  431 

in  tonsillitis,  83 

in  typhoid  fever,  299 

in  typhus  fever,  629 

Calabar  bean,   for  convulsions  of  tetanus,   721 
Calcium  chloride  in  black  vomit  of  yellow  fever, 
739 

lactate  for  hemorrhage  in  typhoid  fever,  296 

permanganate,  in  cholera,  648 
Calmette's  antivenomous  serum  for  leprosy,  673 
Calomel,     anti-emetic     effect    of,     in    bacillary 
dysentery,  360 

in  bacillary  dysentery,  359,  360 

in  cerebrospinal  meningitis,  565,  582 

in  dengue,  642 

in  diphtheria,  452 

in  erysipelas,  774 

in  fibrinous  pleurisy,  114,  125 

in  glandular  fever,  555 

in  infectious  jaundice,  730 

in  malaria,  324,  346 

in  Malta  fever,  658 

in  measles,  493,  505 

in  mumps,  547 

in  paratyphoid  fever,  324 

in  pertussis,  534 

in  plague,  635 

in  pneumonia,  151 

in  poliomyelitis,  594,  604 

in  rat  bite  fever,  746 

in  rubella,  513 

in  scarlet  fever,  397 

in  septicemia,  760 

in  small  pox,  613,  622 

in  tonsillitis,  82,  88 

in  typhoid  fever,  314 

in  typhus  fever,  629 

in  yellow  fever,  738 
Caloric  balance  of  human  body,  11 


Caloric  needs,  determined  by  work,  11 

in  different  callings,  12 

of  resting  •patient,  13,  27 
Caloric  output,  determination  of,  11 
Caloric  requirements,  and  age,  12 

and  body  surface,  13 

and  weight,  13 

of  febrile  patients,  20 

of  man  at  rest,  12,  27 
Caloric  value  of  foodstuffs,  13 
Caloric  values,  Rubner's,  13 
Calorie,  11 

definition  of,  3,  11 

large,  11,  27,  34 

small,  11,  27,  34 
Calories  of  food  required  by  patient  at  rest,  13 

furnished  by  protein,  in  adult,  15 
in  infant,  15 

measure  of  energy  at  rest,  3 

required  in  sickness,  3 

units  of,  in  diet,  17 
Camphor,  for  keeping  mosquitoes  away,  342 

in  anthrax,  683 

in  cholera,  651 

in  diphtheria,  470 

in  febrile  conditions,  6,  9 

in  glanders  and  farcy,  689 

in  grip,  224 

in  malaria,  335 

in  Malta  fever,  660 

in  measles,  495 

in  pneumonia,  176,  204 

in  scarlet  fever,  406,  434 

in  septicemia,  760 

in  typhoid  fever,  299 

in  typhus  fever,  629 

solution  of  in  olive  oil,  6 
Cancrum  oris,  in  Vincent's  angina,  93 
Cantharides  blister,  in  rheumatism,  50 
Capillary  bronchitis,  101 

complicating  measles,  498,  508 
Carbohydrates,  16,  26 

in  typhoid  fever  diet,  284 
Carbolic  acid.    See  Phenol 
Cardiac  complications  in  rheumatism,  53,  67 

in  children,  55,  68 

Cardiac  dilatation  complicating  pneumonia,  192 
Cardiac  disturbances  from  salicylates,  41 
Cardiac  stimulants,  171,  203 
Carpets,  disinfection  of,  in  smallpox,  616 
Carr,  J.  W.,  on  belladonna  in  children,  530 
Carriers.    See  under  the  several  diseases 
Carroll,  on  stegomyia  calopus,  740 

on  yellow  fever,  738 
Carter  on  typhoid  fever,  298 

on  yellow  fever,  739 

Castor  oil,  in  bacillary  dysentery,  359,  360,  361, 
371 

in  epidemic  influenza,  243 

in  fibrinous  pleurisy,  114,  125 

in  glandular  fever,  555 

in  Malta  fever,  658 

in  measles,  493,  505 

in  poliomyelitis,  597 

in  rubella,  513 

in  scarlet  fever,  397 

in  septicemia,  760 

in  typhoid  fever,  292 

in  typhus  fever,  629 

methods  of  administering,  360 
Catabolism,  protein,  influenced  by  pyrexia,  20 
Catharsis,  in  bacillary  dysentery,  359 

in  diphtheria,  452 

in  epidemic  influenza,  243 

in  erysipelas,  774 

in  Malta  fever,  658,  661 

in  measles,  493,  505 

in  poliomyelitis,  597 

in  rat  bite  fever,  746 

in  rheumatism,  35 

in  Rocky  mountain  spotted  fever,  666 

in  scarlet  fever,  397 

in  smallpox,  613,  622 

in  septicemia  and  pyemia,  760,  769 


INDEX 


785 


Catharsis,  in  typhoid  fever,  292 

in  typhus  fever,  629 
Cathartics  in  febrile  conditions,  4,  9 
Catheter,  use  of,  for  tympanites  in  typhoid  fever, 

293 

Cattle,  foot  and  mouth  disease  of,  693 
Cauterization,  contraindicated  in  tetanus,  714 

in  fibrinous  pleurisy,  116,  126,  187 

in  noma  of  measles,  500,  509 

in  rabies,  700,  708 

Cecil,  on  foreign  protein  therapy  in  rheumatism, 
59 

on  pneumqcoccus  vaccines,  194 
Cell  destruction,  expression  of,  26 
Cell,  energy  transformer,  10 

vitality  of,  10 
Ceratum  cantharidis,  50,  67,  and  see  Fly  blis 

ter 

Cerebral  disturbances  in  typhoid  fever,  298 
Cerebral  symptoms  from  sahcylates,  41 
Cerebrospmal  fluid,  in  cerebrospinal  meningitis, 

568,  571 
Cerebrospinal  meningitis,  560 

bed  in,  563,  580 

care  of  bladder  in.  567,  583 
of  bowels  in,  565,  582 
of  eyes  in,  565,  582,  588 
of  mouth  in,  564,  581 
of  nose  in,  564,  582 
of  patient  in,  561,  563,  581 
of  skin  in,  564 

carriers  of,  561,  579,  589 

causative  agent  of,  560 

cerebrospinal  fluid  in,  568,  571 

changes  in  mentality  in,  577 

chronic  cases  of,  576,  587 

complications  in,  577,  587 

convalescence  in,  578,  589 

convulsions  in.  566.  583 

delirium  in,  566.  582 

diet  in.  563.  581 

disinfection  of  secretions  in,  565,  580 
of  utensils  in,  580 

disposal  of  secretions  in,  565 

distension  of  bladder  in,  567,  583 

distribution  of  family  in,  560,  579 

drinks  in,  564 

drug  treatment  in,  567 

ear  complications  in,  577,  588 

early  use  of  serum  treatment  in,  573 

exacerbations  of,  576,  588 

eye  complications  in,  577,  588 

fulminating  cases  of,  575,  587 

hydrocephalus  in,  576.  587 

incubation  period  of,  561 

intravenous  treatment  of,  574,  583,  587 

intraspinal  treatment  of.  568,  584 

isolation  of  contacts,  561 

joint  complications  in,  577.  588 

lumbar  puncture  in,  569,  584 

meningococcic  endocarditis  in,  578 

meningococcic  serum  and  mortality  in,  573 

mortality  from,  577 

otitis  in,  577 

paralysis  in,  577 

precautions  in  sick-room  in,  563,  580 
of  nurse  in,  562,  580 
of  physician  in,  562,  580 

prophylaxis  in,  578,  588 

puncture  of  ventricles  in,  576,  587 

pyelitis  in,  578,  588 

quarantine  in,  560,  579,  589 

relapses  in,  576,  588 

restlessness  in,  566,  582 

room  in,  562,  580 

septic  pneumonia  in,  578 

serum  treatment  of,  567,  573,  578,  583 

sleeplessness  in,  566,  582 

specific  treatment  of,  567,  583 

summary  of  treatment  of,  579 

support  of  circulation  in,  566,  583 

symptomatic  treatment  of,  566,  582 

treatment  of  nausea  in,  565,  582 

vaccines  in,  576,  578 


Cerium  oxalate,  in  anthrax,  683 

in  cerebrospinal  meningitis,  566 

in  infectious  jaundice,  730 

in  Malta  fever,  659 

in  scarlet  fever,  397 

in  typhoid  fever,  295,  315 
Chaparro  amargosa,  in  amebic  dysentery,  382 
Charbon,  678 

Charta  sinapis.    See  Mustard 
Chaulmoogra  oil,  in  leprosy,  671,  672,  674,  676 
Cheese,  food  value  of,  18 

Chenopodium,  oil  of,  in  amebic  dysentery,  383 
Chest  compresses,  in  bronchitis  of  measles,  498 

in  bronchopneumonia  of  measles,  496 

in  pneumonia,  157 
Chicken,  food  value  of,  17 
Chicken  pox,  515,  and  see  Varicella 
Childhood,  laryngitis  in,  98,  100 

rheumatism  in,  30,  55 
Chloral,  in  anthrax,  683,  684,  685,  686 

in  cerebrospinal  meningitis,  566 

in  encephalitis  lethargica,  275 

in  Malta  fever,  659 

in  pertussis,  535,  543 

in  pneumonia,  202 

in  rabies,  706 

in  scarlatinal  nephritis,  421 

in  small  pox,  615 

in  tetanus,  719,  726 
Chloralamid,  in  dengue,  643 

in  epidemic  influenza,  246 

in  erysipelas,  774,  779 

in  Malta  fever,  659 

in  measles,  495,  507 

in  pneumonia,  169 

in  rheumatism,  37 

in  scarlet  fever,  407 

in  septicemia,  762,  770 

in  small  pox,  615 

in  tonsillitis.  84,  89 

in  typhoid  fever,  298,  317 
Chloretone,  for  tetanus,  720,  726 
Chloride  of  lime,  in  glanders  and  farcy,  690 
Chloroform,  in  anthrax,  684 

in  pertussis,  528,  535,  543 

in  rabies,  706 

in  scarlatinal  nephritis,  422 

in  tetanus,  719,  726 
Cholecystitis,  in  typhoid  fever,  298 
Cholera,  Asiatic,  646 

anuria  in,  649,  654 

bed  in,  646 

cathartics  in  early  treatment  of,  647,  654 

cause  of,  646 

circulation  in,  647 

complications  of,  651 

convalescence  from,  652,  654 

diet  in,  646,  653 

early  treatment  of,  647 

hyperpyrexia  in,  649 

isolation  in,  646,  651,  653 

mortality  of,  646 

precautions  in  sick-room  in,  646,  653 
of  nurse  in,  646,  653 
of  physician  in,  646,  653 

prophylactic  inoculation  in,  651 

prophylaxis  of,  651,  655 

quarantine  in,  646,  651,  653 

rest  in,  653 

specific  treatment  of,  650 

stage  of  collapse  in,  647,  649.  654 
of  reaction  in,  649 

stimulants  in,  650 

summary  of  treatment  in,  653 

uremia  in,  650 

vaccines  in,  651 

vomiting  in,  649,  654 

water  in,  647 
Chorea.  59 

autoserotherapy  in,  61 

in  rheumatism,  59,  69 

local  measures  in,  60 

treatment  of,  59,  69 

vaccines  in  treatment  of,  60 


786 


INDEX 


Chromic  acid,  in  Vincent's  angina.  92.  93 
Cinchonism,  333    " 

Circulation.    See  under  the  several  diseases 
Circulatory  failure  in  febrile  conditions,  6 
Citronella  for  keeping  mosquitoes  away,  342 
Climate,  change  of,  in  convalescence  from  per- 
tussis, 537 

in  convalescence  from  scarlatinal  nephritis  423 
Clough,  on  foot  and  mouth  disease,  693 
Coagulen,  in  nose  bleed  of  diphtheria,  467 
Coakley,  on  nasal  hemorrhage,  534 

on  scarification  in  edema  of  the  larynx,  99 
Coal-tar  group,  antipyretics  of,  7 
contraindicated  in  typhus  fever,  628 
in  encephalitis  lethargica,  274 
in  epidemic  influenza,  244,  265 
in  febrile  conditions,  6 
in  fibrinous  pleurisy,  118,  126 
in  grip,  218,  231 
in  pneumonia,  170 
in  poliomyelitis,  596,  605 
in  small  pox,  614,  622 
in  tonsillitis,  83,  89 

Cocaine,  for  C9ugh  in  bronchitis,  106,  110 
for  earache  in  scarlet  fever,  411 
for  lumbar  puncture,  570 
for  vomiting  in  typhoid  fever,  295,  315 
in  coryza,  73 
in  diphtheria,  466 
in  epidemic  influenza,  251 
in  infectious  jaundice,  730 
in  Malta  fever,  659 
in  pertussis,  534 
in  rabies,  707 

in  rhinitis,  73  , 

in  yellow  fever,  739 
Codeine,  in  anthrax,  683 
in  bronchitis,  106,  110,  498 
in  bronchopneumonia,  497 
in  cerebrospinal  meningitis,  566 
in  chorea,  60 
in  chronic  glanders,  497 
in  dengue  642 

in  encephalitis  lethargica,  274,  275 
in  epidemic  influenza,  245,  246,  250 
in  fibrinous  pleurisy,  118,  126 
in  grip,  225,  233 
in  infectious  jaundice,  730,  733 
in  laryngitis,  96,  99 
in  pertussis,  531,  541 
in  pneumonia,  166,  168,  170 
in  poliomyelitis,  596 
in  rheumatism,  37 
in  rhinitis,  76 

in  septicemia  and  pyemia,  761 
in  tonsillitis,  84,  89 
in  trench  fever,  752,  755 
Cohnheim,  on  food,  12 
Cold  in  the  head,  71,  and  see  Coryza 
Cold,  in  febrile  conditions,  7,  9 
in  hyperpyrexia,  6 
in  scarlet  fever,  406,  432 
in  septicemia,  760,  761 
in  rheumatism,  49 
Cold  air,  for  diphtheria,  471 

for  measles,  489,  503 
Cold  applications,  for  adenitis  in  glandular  fever, 

556 

for  bronchitis,  105,  109 
for  conjunctivitis  complicating  measles,  501 
for  hyperpyrexia,  6,  7 
in  scarlet  fever,  401 

for  membranous  angina  in  scarlet  fever,  401 
Cold  bath  in  pneumonia,  159 
Cold  compresses,  in  laryngitis,  97 

in  laryngitis  complicating  measles,  498 
in  pericarditis  in  pneumonia,  185 
in  pneumonia,  157 
in  rheumatism,  49 

Cold  pack,  for  delirium  in  septicemia,  761 
for  fever  in  small  pox,  614 
in  pneumonia,  161 
in  rheumatism,  53 
Cold  sponges,  for  delirium  in  septicemia,  761 


Cold  sponges,  in  pneumonia,  161 
Cold  water,,  for  bronchopneumonia  complicating 
measles,  496 

in  pneumonia,  161 

in  scarlet  fever,  407 

in  typhoid-fever,  299,  and  see  Brand  bath 

treatment,  see  Hydrotherapy 
Cole,  on  pneumonia,  129 
Cole  s  method  of  desensitization  in  pneumonia 

136 
Coleman,  on  typhoid  fever,  22,  23,  25,  26,  283, 

Collapse,  due  to  antipyretics,  223 

during  bath  in  measles,  493 

in  bacillary  dysentery,  373 

in  diphtheria,  468,  483 

in  malaria,  325 

in  measles,  494 

in  pernicious  malaria,  335 

m  pneumonia,  177,  204 

in  septicemia,  760,  769 

threatened,  in  typhoid  fever,  299,  318 
Collargol,  in  trench  fever,  753,  755 
Collodion,  in  erysipelas,  775,  776 
Colomc    irrigation,    for    ileocolitis    complicating 

in  fibrinous  pleurisy,  114,  126 
Conner,  on  intravenous  administration  of  sali- 

cylates,  47 
on     thrombophlebitis     complicating     typhoid 

Convalescence.    See  under  the  several  diseases 
Convulsions.    See  under  the  several  diseases 
Coryza,  71,  and  see  Rhinitis,  acute 

occurring  in  epidemic  influenza,  251 
Cough,  in  bronchitis,  102,  106,  110 
complicating  measles,  498 

in    bronchopneumonia    complicating   measles, 

in  coryza,  75 

in  epidemic  influenza,  237,  250 

in  fibrinous  pleurisy,  113,  118,  126 

in  glanders,  689,  691 

in  laryngitis,  96,  99 

in  pertussis,  525,  540 

in  pneumonia,  161,  200 

in  rhinitis,  78 

source  of  exhaustion,  1 
Cqunterirritation,  in  bronchitis,  104,  109 

in  fibrinous  pleurisy,  116,  126 

in  pericarditis  complicating  pneumonia   187 

in  rheumatism,  50,  67 

in  scarlatinal  nephritis,  420 
Cowling's  rule  for  dosage,  37 
Craig,  on  dengue,  641 
Cream,  food  value  of,  17 

Creatin  and  metabolism,  in  acute  infectious  dis- 
eases, 24 
Creatinin  and  metabolism,   in  acute  infectious 

diseases,  22 

Creatinin  coefficient,  23 
Creosote,  in  bronchitis,  105,  109 

complicating  measles,  498 
in  bronchopneumonia,   complicating  measles, 

in  cough,  of  glanders,  689 

in  pertussis,  528 
Crockery,  disinfection  of,  281 
Croup,  spasmodic,  differentiated  from  laryneeal 

diphtheria,  464 
Croup  kettle,  in  laryngitis,  96,  99 

in  pertussis,  527 

in  scarlet  fever,  401 
Gumming,  on  rabies,  701 
Cupping,  in  bronchitis,  104,  109 

in    bronchopneumonia    complicating    measles, 
497 

in  fibrinous  pleurisy,  117 

in  pneumonia,  165 

in  pulmonary  edema,   in  epidemic  influenza, 

in  pneumonia,  17.9 
in  scarlatinal  nephritis,  419 
technique  of,  164 


INDEX 


787 


Cuahny  on  belladonna,  529 
Cyanosis,  due  to  antipyretics,  223 
in  epidemic  influenza,  238,  249 

Dakin's  solution,  in  anthrax,  682 
in  streptococcus  empyema,  212 
Dandy  fever,  641,  and  see  Dengue 
Deafness,  from  quinine,  333 
from  salicylates,  40 
in  cerebrospinal  meningitis,  577 
De-amidation,  defective,  24 
Delafield,  method  in  pleurisy  with  effusion,  119, 

126 

on  bronchopneumonia,  208 
prescription  for  dysentery,  361 

for  pneumonia,  166 

Delirium,  from  belladonna,  control  of,  531 
from  salicylates,  40 
in  anthrax,  684 
in    bronchopneumonia    complicating    measles, 

497 

in  cerebrospinal  meningitis,  566,  582 
in  epidemic  influenza,  246,  259,  266 
in  erysipelas,  774,  779 
in  hyperpyrexia,  53 
in  infectious  jaundice,  731 
in  measles,  494 
in  plague,  636 
in  pneumonia,  168 
in  rheumatism,  40,  53,  61,  70 
in  scarlet  fever,  407 
in  septicemia,  761,  770 
in  small  pox,  614,  623 
in  typhoid  fever,  317 
in  typhus  fever,  629 
Delousmg,  in  trench  fever,  753,  755 

in  typhus  fever,  627.  633 
Dengue,  641 
bed  in,  641,  643 
care  of  bowels  in,  642.  644 
circulation  in,  642,  644 
complications  in.  643,  645 
convalescence  from,  643,  645 
diagnosis  of,  643 
diet  in,  642,  644 
fever  in,  642,  644 
headache  in,  642 
hemorrhages  in,  643 
infecting  agent  in,  641 
insomnia  in,  642,  644 
local  treatment  of  pains  in.  642 
mortality  in,  641 
mosquito  carrier  of,  641,  643 
nervous  symptoms  in,  643,  644 
pains  in,  642,  644 
prophylaxis  of,  643,  645 
room  in,  641,  643 
summary  of  treatment  of,  643 
transmission  of,  641 
water  in,  642,  644 
Dermacentor,  in  Rocky  mountain  spotted  fever 

664 
Dermacentroxenus,  in  Rocky  mountain  spotted 

fever,  664 

Desensitization,  in  pneumonia,  135,  136 
Diaphoresis,  in  scarlatinal  nephritis,  417,  421 

in  scarlet  fever,  417,  438 
Diarrhea,  in  anthrax,  684,  686 
in  bacillary  dysentery,  364,  372 
in  epidemic  influenza,  246 
in  infectious  jaundice,  730,  733 
in  pertussis,  534,  542 
in  plague,  636,  640 
in  poliomyelitis,  597,  606 
in  typhoid  fever,  294,  315 
in  typhus  fever,  633 
Diet.    See  under  the  several  diseases 
measure  of  in  calories,  17 
physiology  of,  in  febrile  conditions;  3 
summary  of,  27 

Dietary,  proportion  of  foodstuffs  in,  16 
Dietetics,  science  and  art  of,  27 
Digitalis,  in  acute  febrile  conditions,  6 
in  anaphylactic  shock  in  pneumonia,  145 


Digitalis,  in  anthrax,  683 

in  bacillary  dysentery,  365,  373 

in  cerebrospinal  meningitis,  566 

in  cholera,  650 

in  diphtheria,  470 

in  glanders  and  farcy,  690 

in  Malta  fever,  659 

in  pleurisy  with  effusion,  124 

in  pneumonia,  145,  171 

in  pneumonia  complicating  epidemic  influenza, 

247 

in  rheumatic  fever,  54 
in  scarlatinal  nephritis,  420 
in  scarlet  fever,  404,  434 
in  septicemia  and  pyemia,  762,  770 
in  typhoid  fever,  299 
in  typhus  fever,  629 
Digitahzation,  171,  203,  667 
Diphtheria,  443 

active  immunization  in,  447 
adenitis  complicating,  473 
anemia  in,  485 
angina  in,  465 
antitoxin,  454,  479 
bath  in,  450 
bed  in,  450 

bronchopneumonia  complicating,  473 
cardio-vascular  apparatus  in,  467,  469,  482 
care  of  bowels  in,  452 
of  genitals  in,  452 
of  mouth  in,  451 
of  nose  in,  451,  452,  466 
of  patient  in,  450,  478 
of  teeth  in,  451 
of  throat  in.  451,  465 
carriers  of,  475.  485 
complicating  measles,  501 
convalescence  from,  474,  484 
culture  taking  in,  444,  477 
death  in.  468,  483 
diet  in.  450.  478 
differential  diagnosis  of.  464 
distribution  of  family  in,  444,  477 
extubation  in,  463 
feeding  in,  450,  478 
fever  in,  465 

hemorrhage  from  nose  in,  467,  482 
hot  fomentations  in.  462,  465 
immunity  to,  448 
inhalations  of  steam  in,  461 
intubation  in,  462 

laryngeal,  460,  481,  and  see  Laryngeal  diph- 
theria 

antitoxin  treatment  of,  455,  481 
differential  diagnosis  of,  464 
dosage  of  antitoxin  in,  455 
extubation  in,  463 
intubation  in,  462 

symptomatic  treatment  of,  465,  481 
late  circulatory  failure  in,  468 
malaise  in,  443 

malignant,  dosage  of  antitoxin  in,  455 
mortality  in,  456 
nasal,  451,  482 

antitoxin  treatment  of,  455 
dosage  of  antitoxin  in,  455 
nephritis  and,  473,  484 
open-air  treatment  of,  471 
otitis  complicating,  473 
paralyses  in,  471,  483 
pharyngeal,  dosage  of  antitoxin  in,  455 
post-intubation,  treatment,  463 
precautions  of  nurse  in,  449,  478 

of  physician  in,  449,  478 
prophylaxis  of,  476 
quarantine  for,  474,  485 
rest  in,  450,  478 
room  in,  448,  449,  450,  477,  478 
Schick  reaction  for,  444,  445,  449,  450 
serum  therapy  in,  453 
sterilization    and    fumigation    following,    475, 

485 

summary  of  treatment  of,  477 
symptoms  of,  443 


788 


INDEX 


Diphtheria,  syncope  in,  468,  483 

taking  cultures  in,  444 

treatment  of  symptoms  of,  465 
Diplosal,  in  rheumatism,  44,  65,  and  see  Salicy- 
lates 

in  tonsillitis,  83,  89 

Disinfection.    See  under  the  several  diseases 
Distribution  of  family.     See  under  the  several 

diseases 

Diuresis  in  scarlet  fever,  439 
Diuretics,  in  pleurisy  with  effusion,  123,  127 

in  scarlatinal  nephritis,  420 
Diuretin,  in  scarlatinal  nephritis,  420 

in  pleurisy  with  effusion,  123 
Dobell's  solution,  in  bacillary  dysentery,  357 

in  cerebrospinal  meningitis,  564,  579' 

in  diphtheria,  452,  466,  467,  476 

in  epidemic  influenza,  242 

in  foot  and  mouth  disease,  694 

in  glandular  fever,  555 

in  measles,  492 

in  mumps,  525 

in  pertussis,  525 

in  scarlet  fever,  396,  400 

in  varicella,  517 

Dog,  symptoms  of  rabies  in,  702 
Dogs  and  prevention  of  rabies,  707 
Dosage,  rules  for,  in  children,  37 
Dover's  powder,  in  bronchitis,  104,  109 

in  bronchitis  complicating  measles,  498 

in    bronchopneumonia    complicating    measles, 
497 

in  cholera,  647 

in  pertussis,  531,  541 

in  rhinitis,  72 

Drainage,  in  streptococcus  empyema,  213 
Draper,  on  poliomyelitis,  595 
Drinks.    See  under  the  several  diseases. 
Dry  tap,  in  lumbar  puncture,  572 
Dudley,  on  anthrax,  680 
Dumb  rabies,  702 

Dunn,   on   cardiac   complications  in   rheumatic 
fever,  55 

on  serum  treatment  of  cerebrospinal  menin- 
gitis, 576 

Duval  and  Gurd,  on  leprosy,  674 
Dyer,  on  leprosy,  673 

Dysentery,  amebic,  374,  and  see  Amebic  dysen- 
tery 

bacillary,  353,  and  see  Bacillary  dysentery 
Dyspnea,  due  to  impurities  in  salicylates,  40 

in  epidemic  influenza,  238,  249 

in  fiorinous  pleurisy,  118,  126 

in  pneumonia,  179 

in  poliomyelitis,  600,  606 

Earache,  in  measles,  499,  508 

in  scarlet  fever,  411 
Ears,  and  see  Otitis 

buzzing  in,  from  salicylates,  40,  41 
care  of,  in  pneumonia,  149 
in  scarlet  fever,  392,  411 
changes  in,  due  to  quinine,  333 
complications  of,  in  cerebrospinal  meningitis, 

577 

examination  of  in  infections,  in  children,  443 
Edema,  angioneurotic,  due  to  antipyretics,  223 
in  scarlatinal  nephritis,  420 
in  scarlet  fever,  421,  438,  439 
of  larynx,  98,  100 

intubation  in,  99,  100 
scarification  in,  98,  100 
tracheotomy  in,  99,  100 
pulmonary,  in  pneumonia,  178 
subglottic,  differentiated  from  laryngeal  diph- 
theria, 464 

Effusions,  in  rheumatism,  67 
Eggleston's  rule  for  digitalization,  171,  203 
Eggs,  food  value  of,  17 

Einhorn's  tube,  use  of  in  typhoid  carriers,  305 
Elastic  belt  in  pertussis,  526,  533 
Electric  pad,  in  fibrinous  pleurisy,  115,  126 
Electricity  for  paralysis  of  extremities  in  polio- 
myelitis, 601,  607 


Elser  and  Huntoon  on  cerebrospinal  meningitis, 

.561 
Embolism',  in  pneumonia,  190,  206 

in  septicemia  and  pyemia,  763,  771 
Emetine,  in  amebic  dysentery,  376,  384 

toxic  dose  of,  380 

Emphysema,  in  epidemic  influenza,  256 
Empyema,  112,  125,  127 

in  epidemic  influenza,  253 

in  pneumococnus  pneumonia,  181,  187 

in  streptococcus  pneumonia,  209,  211 

in  typhus  fever,  630 

Empyema,  pneumococcus,  112,  and  see  Empyema 
Empyema    (streptococcus  and  influenza  types), 
207,  211 

aspiration  in,  211 

Dakin's  solution  in,  212 

drainage  in,  213 

summary  of  treatment  of,  215 

treatment  of,  211 
Encephalitis  lethargica,  271 

bed  in,  274,  275 

care  of  body  in,  274,  276 
of  bowels  in,  274,  276 

convalescence  in,  275,  276 

course  of,  273 

diet  in,  274,  276 

drinks  in,  274,  276 

fever  in,  275,  276 

hyperesthesia  in,  275,  276 

in  epidemic  influenza,  258 

insomnia  in,  275,  276 

irritability  and  restlessness  in,  275,  276 

lumbar  puncture  in,  275,  276 

mortality  in,  273 

pains  and  headaches  in,  274,  276 

paresthesia  in,  275,  276 

pathology  of,  271 

prognosis  of,  273 

room  in,  274,  275 

sequelae  of,  273 

summary  of  treatment  of,  275 

symptomatology  of,  271 
Endocarditis,  in  erysipelas,  777 

in  measles,  501 

in  pneumonia,  190 

in  rheumatism,  53 

in  scarlatinal  nephritis,  422 

in  scarlet  fever,  423 

in  septicemia,  762,  763 

in  septicopyemia,  758 

meningococcic,  578 
Endogenous  metabolism,  23 
Endotoxins,  453 

Enemata,    in    bronchopneumonia    complicating 
measles,  498 

in  diphtheria,  470 

in  epidemic  influenza,  243,  251 

in  erysipelas,  774 

in  Malta  fever,  658 

in  plague,  635 

in  pneumonia,  152 

in  poliomyelitis,  594 

in  rheumatism,  36 

in  septicemia,  760 

in  tympanites,  251,  294 

in  typhoid  fever,  292 

milk  and  molasses,  294 

nutrient,  470 

peppermint,  294 

soapsuds,  36 

turpentine,  293 
Entamceba  coli,  374,  376 

histolytica,  353,  374,  376 

Enteroclysis,  in  bronchopneumonia  complicating 
measles.  498 

in  circulatory  failure  in  diphtheria,  470 

in  scarlatinal  nephritis,  422 

in  scarlet  fever,  440 
Environment,  change  of,  in  bacillary  dysentery, 

368 
Epidemic  influenza,  235 

abdominal  symptoms  in,  260 

abscess  of  lung  in,  254,  268 


INDEX 


789 


Epidemic   influenza,  abscess  of  muscles  in,  260, 

270 

aches  and  pains  in,  244,  265 
acidosis  in,  251,  267 
bed  in,  240,  263 
blood  in,  238 
bronchiectasis  in,  255 
care  of  bowels  in,  243,  264 

of  eyes  in,  243,  264 

of  mouth  in,  242,  263 

of  nose  in,  243,  264 

of  patient  in,  242,  263 

of  teeth  in,  242,  264 
carriers  of,  261 
circulation  in,  246,  247,  266 
convalescence  in,  260,  269 
cough  in,  237,  250,  267 
cyanosis  in,  238,  249 
delayed  resolution,  252,  267 
delirium  in,  246,  266 
diarrhea  in,  246,  266 
diet  in,  244,  265 
dyspnea  in,  249 
emphysema  in,  256 
empyema  in,  253,  268 
encephalitis  lethargica  in,  258 
epistaxis  in,  238 
erythema  in,  238 
etiology  of,  235 
fluids  in,  244,  265 
headaches  in,  245,  264,  265 
heart  and  vessels  involved  in,  256,  268 
incubation  period  of,  237 
insomnia  in,  245 
isolation  in,  239,  262 
kidneys  involved  in,  257,  258,  269 
meningitis  in,  258 
mental  disturbance  in,  259,  268 
nervous  system  involved  in,  258 
nervousness  in,  265 
neuritis  in,  259 
onset  of,  237 
otitis  media  in,  260 
parotitis  in,  260 
pathology  of,  235 
phlebitis  in,  257,  269 
pleurisy  in,  253,  268 
pneumonia  in,  236,  239,  246,  266 
precautions  for  nurse  in,  241,  263 

for  physician  in,  241,  263 
prophylaxis  of,  261,  270 
prostration  in,  238 
pulmonary  edema  in,  248,  267 
pulse  in,  238 
respiration  in,  238 
room  in,  240,  262 
summary  of  treatment  of,  262 
symptomatology  of,  237 
temperature  in,  238 
treatment  of,  239.  262 
tuberculosis  in,  255 
tympanites  in,  251,  267 
upper  air  passages  involved  in,  256 
urine,  retention  of  in,  238 
vaccines  in,  262 
vomiting  in,  246,  266 
warnings  to  family  in,  242,  263 
Epinephrin.    See  Adrenalin 
Epistaxis,  in  epidemic  influenza,  238,  256 

in  pertussis,  534 

Epsom  salts,  in  bronchitis,  103,  109 
in  dengue,  642 
in  diphtheria,  452 
in  epidemic  influenza,  243 
in  erysipelas,  774 
in  fibrinous  pleurisy,  114,  125 
in  grip,  217,  231 
in  laryngitis,  95,  99 
in  Malta  fever,  658 
in  mumps,  547 
in  plague,  635 
in  pneumonia,  151 
in  rheumatism,  35 
in  scarlatinal  nephritis,  417 


Epsom  salts,  in  scarlet  fever,  397 

in  septicemia  and  pyemia,  760 

in  tonsillitis,  82,  88 

in  typhoid  fever,  292,  314 

in  yellow  fever,  738 
Erdman,  on  erysipelas,  775,  777 
Eruptions.    See  Skin  eruptions 
Erysipelas,  772 

bedin,  773,  778 

care  of  body  in,  774,  778 
of  bowels  in,  774,  778 
of  eyes  in,  774 
of  mouth  in,  774 

circulation  in,  774 

complications  of,  777,  779 

creatinin  in,  24 

delirium  in,  774,  779 

diet  in,  773,  778 

disinfection  in,  777,  780 

facial,  772,  773 

local  treatment  of,  775,  779 

fever  in,  774,  778 

headache  in,  774,  778 

immunity  in,  777 

in  infants,  776,  779 

incubation  period  of,  772 

insomnia  in,  774,  779 

isolation  in,  773,  778 

local  treatment  of,  775,  779 

migratory,  776,  779 

nervousness  in,  774,  778 

of  extremities,  776,  779 

organism  of,  772 

prophylaxis  of,  777.  780 

room  in,  773,  778 

specific  treatment  of,  776,  779 

summary  of  treatment  of,  778 

symptomatic  treatment  of,  774,  778 

symptoms  of,  772 

transfusion  of  blood  in,  777 

vaccine  treatment  of,  776 
Erythema,  from  antipyretics,  223 

from  diphtheria  antitoxin,  458 

from  quinine,  333 

from  salicylates,  40 

in  epidemic  influenza,  238 

in  scarlet  fever,  387 

in  septicemia,  763 

in  varicella,  516   ' 
Eserine.    See  Physostigmine 
Euquinine,  in  malaria,  334 
Ewing,     on     typhoid     fever     metabolism,     25, 

286 

Exogenous  metabolism,  23 
Expansion   of    lung   in   pleurisy   with    effusion, 

technique  of,  124 
Expectorants,  in  bronchitis,  106,  107,  110 

in  pneumonia,  166,  201 
Exploratory  puncture,  in  pleurisy  with  effusion, 

120,  127 
Exsanguination,  in  typhoid  fever,  treatment  of, 

316 

Extubation,  463 
Eyes,    See  under  the  several 


Faget's  sign,  in  yellow  fever,  735 
Family,  distribution  of.     See  under 


the  several 


Farcy,  687,  and  see  Glanders 
acute,  689,  692 
chronic,  687,  691 

serum  therapy  in,  688 

specific  treatment  of,  688 

treatment  of  local  lesions  in,  688,  689 

vaccine  treatment  of,  688,  691 
general  treatment  of,  687 
isolation  in,  690 
mortality  in,  687 
precautions  of  nurse  in,  690 

of  physician  in,  690 
prophylaxis  of,  690,  692 
summary  of  treatment  in,  690 
Fat,  in  acute  infectious  diseases,  16,  26 
in  typhoid  fever  dietary,  284 


790 


INDEX 


Febrile  conditions,  1 

aconite  in,  6 

antipyretics  in,  7,  9 " 

caffeine  in,  6,  9 

camphor  in,  6,  9 

cathartics  in,  5,  9 

diet  in,  3,  8 

digitalis  in,  6,  9 

drugs  in,  5,  6,  9 

fresh  air  in,  4,  8 

rest  in,  2,  8 

specific  treatment  of.     See  under  the  several 
diseases 

strophanthin  in,  6 

strychnine  in,  6 

summary  of,  7 

water  in,  3,  4,  5,  9 

Febrile  patient,  calories  required  by,  20 
Febris  carnis,  286 
Ferenbaugh,  on  Malta  fever,  656 
Fever,  1,  and  see  under  the  several  diseases 

meaning  of,  19 

open  air  treatment  of,  4 

in  relation  to  disease,  19 

starvation  in,  29 

water  needs  in,  29 

Fitzgerald,  on  tetanus  antitoxin,  718 
Fixed  virus,  of  rabies,  702 
Fleas,  and  plague,  634 
Flexner,  on  cerebrospinal  meningitis,  569,  573 

serum,  for  bacillary  dysentery,  361 

serum,  mortality  with  in  cerebrospinal  menin- 

itis,  577 

Fluoform,  in  pertussis,  532 

Fly  blister,  in  local  treatment  of  rheumatism,  50 
Focal  symptoms,  in  encephalitis  lethargica,  272 
Folin,  analysis  of  urines,  22,  25 
Foodstuffs,  standard  portions  of,  16 
Fomentations,  application  of,  163 

in  bacillary  dysentery,  362 

in  bronchitis,  105,  109 

in  bronchopneumonia  complicting  measles,  498 

for  buboes,  in  plague,  636 

in  diphtheria,  462 

in  fibrinous  pleurisy,  115,  126 

in  glandular  fever,  556 

in  laryngitis,  97 

in  mumps,  547 

in  pericarditis  of  pneumonia,- 187 

in  pneumonia,  163 

for  retention  of  urine,  in  Malta  fever,  658 

in  rheumatism,  49 

in  scarlatinal  nephritis,  420 
Food,  harm  of  withholding  in  fevers,  20 
Foodstuffs,  proportion  of  in  average  dietary,  16 

Rubner's  figures  for  caloric  value  of,  13,  14 
Food  values,  in  units  of  100  calories,  17 
Foot  and  mouth  disease,  693 

bed  in,  694,  696 

care  of  bowels  in,  695,  696 
of  eyes  in,  695,  697 
of  mouth  in,  694,  697 
of  nose  in,  697 
of  teeth  in,  694 

circulation  in,  694 

diarrhea  in,  697 

diet  in,  694,  696 

fever  in,  694,  696 

gastro-intestinal  symptoms  in,  695,  697 

isolation  in,  694 

precautions  of  nurse  in,  694,  696 
of  physician  in,  694,  696 

prognosis  of,  695 

prophylaxis  of,  695 

rest  in,  694,  696 

room  in,  694,  696 

summary  of  treatment  of,  696 

vesicles  and  ulcers  of  skin  in,  695,  697 
Foreign  protein  therapy,  in  rheumatism,  58 
Forks,  disinfection  of,  281 
Fowler's  solution,  in  malaria,  339,  351 
Fresh  air,  in  convalescence  from  pertussis,  537 

in  febrile  conditions,  4,  8 

in  leprosy,  671,  676 


Fresh  air,  in  pneumonia,  155 

in  septicemia.  759 

Friction,  in  connection  with  hydrotherapy,  5 
Frontal  sinus  involvement  in  influenza,  228,  23c 
Fuller's  alkaline  treatment  for  rheumatism,  46 
Fumigation.    See  Disinfection 

Gatch  bed,  147 

G:.3tric  distress,  in  typhoid  fever,  315 

Gastro-intestinal    function,    disturbance    of,    in 

infection,  8,  18,  28 
Gaultheria,  43,  and  see  Wintergreen 
Genitals,  care  of.    See  under  the  several  diseases 
Genito-urinary  infection,  in  epidemic  influenza, 

258 

Gentry  and  Ferenbaugh,   on  Malta  fever,   656 
German  measles,  512,  and  see  Rubella 
Glanders,  687,  and  see  Farcy 

acute,  689,  692 

chronic,  689,  691 

care  of  nose  in,  689,  691 
cough  in,  689,  691 

general  treatment  of,  687 

isolation  in,  690 

mortality  in,  687 

precautions  of  nurse  in,  690 
of  physician  in,  690 

prophylaxis  of,  690,  692 

summary  of  treatment  of,  690 
Glandular  fever,  555 

adenitis  in,  556,  558 

bed  in,  555 

care  of  bowels  in,  555,  558 
of  mouth  in,  555,  558 
of  nose  in,  555 
of  throat  in,  556,  558 

complications  of,  556,  558 

convalescence  from,  557,  559 

diet  in,  555,  557 

fever  in,  556,  558 

glands  involved  in,  555 

incubation  period  of,  555 

inflammation  of  pharynx  in,  556 

isolation  in,  555,  557 

nephritis  in,  556,  and  see  Scarlet  fever,  neph- 
ritis in 

otitis  in,  556 

prophylaxis  in,  557,  559 

room  in,  555,  557 

summary  of  treatment  of,  557 

tonsils  in,  556 

toxemia  in,  556,  558 
Glauber's  salts,  in  bronchitis,  103,  109 

in  erysipelas,  774 

in  fibrinous  pleurisy,  114,  125 

in  laryngitis,  95,  99 

in  Malta  fever,  658 

in  mumps,  547 

in  plague,  635 

in  rheumatism,  35 

in  scarlet  fever,  397 

in  yellow  fever,  738 

Glottis,   edema  of,  complicating  small  pox,  615, 
623 

phlegmon    of,    differentiated    from    laryngeal 

diphtheria,  464 

Goat  fever,  656,  and  see  Malta  fever 
Goats,  carriers  of  Malta  fever  organism,  656 
Goats'  milk,  in  Malta  fever,  657 
Goodman,  on  autoserotherapy  in  chorea,  61 
Gottlieb,  on  caffeine,  in  scarlet  fever,  405 
Graham,  on  dengue,  641 
Gravity  method,  in  lumbar  puncture,  572 
Grip,  216 

antipyretics  in,  218,  223,  231 

antral  involvement  in,  228,  233 

bed  in,  217 

bronchitis  complicating,  227 

care  of  bowels  m,  217,  231 

carriers  of,  230 

change  of  air  in,  229 

complications  of,  225,  233 

convalescence  in,  225,  233 

cough  in,  225,  233 


INDEX 


791 


Grip,  diet  in,  217,  225,  231,  233 

drugs  in,  218,  231 

fever  in,  220,  229,  231,  233 

frontal  sinus  involvement  in,  228,  233 

mastoiditis  complicating,  226,  233 

mental  depression  in,  229,  234 

neuritis  in,  234 

otitis  media  complicating,  226,  233 

pleurisy  in,  227 

pneumonia  in,  226,  233 

prophylaxis  of,  230,  234 

rest  in,  217 

rhinitis  in,  227 

room  in,  231 

sinus  thrombosis  complicating,  226,  233 

sthenic  period  of  toxemia,  218 

summary  of  treatment  of,  231 

symptomatic  treatment  of,  218,  231 

tonics  in,  225,  233 

tonsillitis  in,  227 

tracheitis  in,  224,  232 

Growing  pains  and  rheumatism,  in  childhood,  61 
Guiacol,  in  abscess  of  lung  in  epidemic  influenza, 
255 

in  mumps,  548,  553 
Guiteras,  on  yellow  fever,  736.  739 
Gurd  and  Duval,  on  leprosy,  674 
Gynocardia.    See  Chaulmoogra  oil. 

Haas,  on  adenitis  in  glandular  fever,  556 
Haffkine's  vaccine  for  plague,  635,  638 
Hale,  Worth,  on  toxicity  of  acetanilid,  219 

on  trikresol  and  meningococcic  serum,  569 
Halibut  steak,  food  value  of,  17 
Hanzlik,  on  rheumatism,  39,  44 
Headache.    See  under  the  several  diseases. 
Hearing,  effect  of  antipyretics  on,  223 

effect  of  quinine  on,  333 
Heart  involvement,  in  bacillary  dysentery,  366 

in  epidemic  influenza,  256,  268 

in  malaria,  337,  350 

in  measles,  501 

in  rheumatism,  in  children,  30 

in  scarlet  fever,  423 
Heat,  for  chill  in  malaria,  324 

for  collapse  in  pneumonia,  177 

for  earache  in  scarlet  fever,  411 

for  laryngitis  in  measles,  498 

for  otitis  in  measles,  499 

for  pain  in  bacillary  dysentery,  552 

for  parotitis  in  mumps,  552 

in  fibrinous  bronchitis,  115,  126 

in  malaria,  336 

in  pericarditis,  186 

in  pneumonia,  162 

in  poliomyelitis,  596,  597 

in  rheumatism,  49 

Heine-Medin  disease,  271  and  see  Poliomyelitis 
Hematuria,  from  salicylates,  40 
Hemoglobinuria,  in  blackwater  fever,  343 
Hemoplastin,  in  nose  bleed  of  diphtheria,  467 
Hemorrhage.    See  under  the  several  diseases 
Hepatic  abscess,  in  amebic  dysentery,  377,  379 
Heroine,  for  cough,  in  bronchitis,  106,  110 

in  epidemic  influenza,  250 

in  grip,  225,  233 

in  laryngitis,  96,  99 

in  pertussis,  532 
Herrick,   on   serum   treatment   of  cerebrospinal 

meningitis,  574 

Heyn,  on  rectal  administration  of  salicylates,  47 
Hides,  and  anthrax,  678,  684 
Hill,  Miner  C.,  on  intubation  in  diphtheria,  462 
Hill  on  prognosis  of  tetanus,  721 

on  transmissibility  of  poliomyelitis,  592 
Hilprit,  on  synthetic  sodium  salicylate,  42 
Holt,  croup  kettle,  96,  527 

on  diphtheria,  474 

on  dosage,  of  diphtheria  antitoxin,  456 
of  quinine,  330 

on  mortality,  in  measles,  487 

on  oxygen  inhalations  in  pertussis,  536 

on  pertussis,  528 
Hominy,  food  value  of,  17 


Hooker,  on  blood  transfusions,  767 

Horse  serum,  for  hemorrhage  in  typhoid  fever,  296 

in  poliomyelitis,  605 

in  tetanus,  713 

Horses,  glanders  and  farcy  and,  687 
Hot  air  bath,  in  scarlatinal  nephritis,  417 
Hot  bath,  in  laryngitis,  95,  99 

in  rhinitis,  72 
Hot  compresses,  in  laryngitis  of  measles,  499 

in  scarlatinal  nephritis,  417,  418 
Hot  fomentations,  for  angina  in  laryngeal  diph- 
theria, 465 

in  diphtheria,  462 

in  poliomyelitis,  596 

Hot  milk,  in  laryngitis  complicating  measles,  499 
Hot  pack,  in  chorea,  60 

in  scarlatinal  nephritis,  417,  418 
Hot  water  bag,  in  fibrinous  pleurisy,  115,  126 
Hot  water  bottle,  in  rhinitis,  72 
Hubbard,  ointments  used  by,  in  small  pox,  612 

formula  for  itching,  in  measles,  492 
Huntoon  and  Elser,  on  cerebrospinal  meningitis, 

561 

Hydrocephalus,  in  cerebrospinal  meningitis,  576 
Hydrochloric  acid,  in  acute  infectious  diseases,  18 
Hydrogen  dioxide,  in  local  treatment  of  tetanus, 
714 

in  treatment  of  wounds,  722 
Hydrophobia,  699,  and  see  Rabies 
Hydrotherapy.     See  Baths,  and  also  under  the 
several  diseases 

in  febrile  conditions,  3,  4,  7,  9 
Hydrothorax,  in  scarlatinal  nephritis,  421 
Hyoscine,  for  chorea,  61 

for  convulsions  of  tetanus,  720 

for  delirium,  in  anthrax,  684 
in  epidemic  influenza,  246 
in  erysipelas,  774 

in  cerebrospinal  meningitis,  566 

in  pneumonia,  169 

in  rabies,  707 

in  Rocky  mountain  spotted  fever,  667 

in  septicemia  in  pyemia,  761 
Hyperpyrexia.    See  under  the  several  diseases 
Hypertonic    glucose    solution    in    cerebrospinal 

meningitis,  567 

Hypertonic  solution,  in  cholera,  647,  652 
Hypnotics,  in  pneumonia,  169,  202 

in  rheumatism,  37 

in  small  pox,  615 

Hypodermoclysis,  in  diarrhea  of  bacillary  dysen- 
tery, 365,  373 

in  diphtheria,  471 

with  quinine,  331 

Ice,  for  gastric  distress  in  yellow  fever,  738 
for  nausea,  in  scarlet  fever,  422,  431 
in  vomiting  of  typhoid  fever,  295,  315 
Ice-bag,  application  of,  163 

for  angina,  in  laryngeal  diphtheria,  465 

for  buboes,  in  plague,  636 

for   cerebral   disturbances,    in    typhoid    fever, 

298 
for  delirium,  in  septicemia,  761 

in  pneumonia,  168 

for  gastric  distress,  in  yellow  fever,  738 
for  headache,  in  anthrax,  684 

in  bronchitis,  104,  109 

in  scarlatinal  nephritis,  422 

in  septicemia,  762 

in  small  pox,  614 

for  hemorrhage  in  typhoid  fever,  296 
for  pains,  in  dengue,  642 
in  fibrinous  pleurisy,  115,  126 
in  laryngitis  complicating  measles,  498 
in  pericarditis  complicating  pneumonia,  185 
in  pneumonia,  163 
in  rheumatism,  49 

in  Rocky  mountain  spotted  fever,  667 
in  typhoid  fever,  294 
Ice-cap,  for  headache  in  pneumonia,  168 
in  cerebrospinal  meningitis,  566 
in  measles,  494 
in  scarlet  fever,  407,  413 


792 


INDEX 


Ice-coil.    See  also  Ice-bag 

in  cerebrospinal  meningitis,  566 

in  rheumatism,  49 

in  tympanites  of  typhoid  fever,  294 
Ice-collar,  in  laryngitis,  97 
Ice-poultice,  in  mumps,  548,  553 
Ichthyol,  in  erysipelas,  775,  776 

in  glandular  fever,  556 

in  mumps,  548,  553 

in  scarlet  fever,  413 
Immunity,  active,  454 

passive,  454 

Imperial  drink,  in  rhinitis,  72 
Infantile  paralysis,  590,  and  see  Poliomyelitis 
Infectious  diseases,  acute,  diet  in,  10  to  29 
Infectious  jaundice,  728 

active  immunization  in,  731 

bed  in,  729 

care  of  bowels  in,  730,  732 

colic  in,  733 

convalescence  from,  733 

diarrhea  in,  730,  733 

diet  in,  729,  732 

fever  in,  729,  731 

headache  in,  733 

hemorrhages  in,  731 
.    icteric  stage  of,  729 

incubation  period  of,  728 

jaundice  in,  729,  731 

lesions  of,  728 

nausea  in,  730,  733 

nephritis  in,  731 

nervous  symptoms  in,  731 

organism  of,  728 

pain  in  legs  in,  731,  733 

prophylaxis  of,  731,  734 

room  in,  729 

specific  treatment  of,  730 

summary  of  treatment  of,  732 

symptoms  of,  728 

vomiting  in.  730,  733 

water  in,  732 

Influenza  empyema,  211,  and  see  Empyema,  in- 
fluenza type 

epidemic,  235,  and  see  Epidemic  influenza 

sporadic,  216,  and  see  Grip 

Inhalations,  in  abscess  of  lung  in  epidemic  in- 
fluenza, 255 

in  bronchitis,  105,  109,  110 

in  bronchitis  in  measles,  498 

in  coryza,  74 


in  grip,  225 
in  la 


laryngitis,  96,  98,  99 

in  laryngitis  in  measles,  499 

in  membranous  angina  in  scarlet  fever,  400,  401 

in  pertussis,  527 

in  pneumonia,  165,  201 

in  rhinitis,  74,  77 

in  tracheitis  of  grip,  225,  232 

oxygen,  for  dyspnea  in  pneumonia,  179 
in  pertussis,  536 

steam,  in  bronchopneumonia,  180 

in  bronchopneumonia  complicating  measles, 
497 

in  diphtheria,  461 

in  glanders,  689 

in  laryngitis  in  small  pox,  615 

in  laryngitis  in  typhus  fever,  630 

in  pneumonia,  165 
Inhalers,  96,  99 
Insomnia,  in  anthrax,  683 

in  dengue,  642,  644 

in  encephalitis  lethargica,  272,  275 

in  epidemic  influenza,  245 

in  pertussis,  533,  541 

in  poliomyelitis,  596,  605 

in  rheumatism,  36,  68 

in  septicemia,  761,  770 

in  small  pox,  614,  623 

in  tonsillitis,  84,  89 
Intestinal  anthrax,  679 
Intestinal  infection,  and  rheumatism,  62 
Intracerebral   administration   of  antitoxin,   717, 
725 


Intramuscular  administration  of  antitoxin,  717, 

725  ., 

Intraneural  administration  of  antitoxin,  717,  725 
Intraspinal  administration  of  antitoxin,  716,  725 

of  magnesium  sulphate,  in  tetanus,  719 

treatment  of  cergbrospinal  meningitis,  668,  584 
Intravenous  injection,  of  adrenalin  in  pneumonia, 
177 

of  diphtheria  antitoxin,  457,  480 

of  foreign  protein  in  rheumatism,  58 

of  quinine,  332 

of  salicylates,  47,  66 

of  saline  solution  in  cholera,  647,  652 

of  tetanus  antitoxin,  716,  725 
Intubation,  in  diphtheria,  462 

indications  for,  463 

in  edema  of  larynx,  99 

in  pertussis,  528 

post-intubation  treatment,  463 

procedure,  462 
Iodine,  for  itching  and  burning  of  small  pox,  613 

for  lesions  of  farcy,  689 

for  local  treatment  of  tetanus,  722,  725 

for  odor  of  small  pox,  613 

for  membranous  angina  in  scarlet  fever,  401 

in  fibrinous  pleurisy,  116,  126 

in  rabies,  701 

in  treatment  of  wounds,  722,  725 

in  Vincent's  angina,  92,  93 
lodoform,  for  odor  of  small  pox,  613 

in  glanders,  689 

in  treatment  of  wounds,  722 
Ipecac,  in  amebic  dysentery,  376 

in  anthrax,  681 

in  laryngitis,  96,  98,  99,  100 
Iron,  for  anemia,  in  malaria,  339,  351 
in  scarlatinal  nephritis,  423 

for    convalescence.      See    under    the    several 


Irrigation,    colonic,    for   ileocolitis    complicating 
measles,  500,  509 

in  otitis  of  scarlet  fever,  410 

nasal,  in  diphtheria,  452,  466 
in  glanders,  689 

of  throat,  in  scarlet  fever,  400 

oral,  in  foot  and  mouth  disease,  694 

rectal,  in  bacillary  dysentery,  362,  363 
Isolation.  See  under  the  several  diseases 
Itching  and  burning,  in  measles,  491,  505 

in  small  pox,  612,  621 

in  varicella,  516 

Jackson,  on  plague,  637 

Jacobi,  on  belladonna,  in  pertussis,  530,  540 

Jalap,  in  Malta  fever,  658 

Jalap  powder,  compound,  in  scarlatinal  nephritis, 

James,  on  dosage  of  quinine,  330 

on  relapses  in  malaria,  338 
Jaundice,  complicating  pneumonia,  191 
Jaundice,    infectious,    728,    and    see    Infectious 

jaundice 

Jenner,  on  small  pox,  608 
John  and  Ashurst,  on  tetanus,  711,  714 
Johns,  on  blackwater  fever,  343 

on  malaria,  324,  327 
Joints,  care  of  in  Malta  fever,  658 

in  cerebrospinal  meningitis,  577 

in  rheumatism,  31,  48,  50,  66 

in  scarlatinal  arthritis,  413,  437 

in  septicemia,  763,  771 

Kemp,  on  rheumatism,  54 
Ker,  on  orchitis  in  mumps,  549 

on  pertussis,  528,  534 
Kerr  and  Stimson,  on  rabies,  708 
Kidneys,  complication  of,  in  diphtheria,  473 

in  malaria,  336,  350 
congestion  of,  in  yellow  fever,  739 
functions  of,  393 

hemorrhage  from,  due  to  quinine,  334 
involvement  of,  in  epidemic  influenza,  257 
in  measles,  501 
in  scarlet  fever,  414 


INDEX 


793 


Kidneys,  in  septicemia,  763 
Kilmer's  belt,  in  pertussis,  526,  533 
Klemperer,  on  gastrointestinal  function,  18 
Klercner,  on  typhoid  fever,  24 
Knee-joint,  paracentesis  of,  51 
Knives,  disinfection  of,  281 
Koch,  on  blackwater  fever,  344 

method  of  giving  quinine  in  malaria,  329 
Koumyss,  food  value  of,  17 
Krehl,  on  toxemia,  21 

Krumwiede-Valentine,  method  of  typing  sputum, 
131 

Lamb,  food  value  of,  17 
Lambert,  on  pneumonia,  22,  25 
Langmead,  on  rheumatism  in  children,  31 
Laryngeal  diphtheria,  460,  and  see  Diphtheria, 

laryngeal 

Laryngeal  spasm,  in  pertussis,  528 
Laryngitis,  acute,  94 

abortive  treatment  of,  95,  99 

care  of  bowels  in,  95,  99 
in  children,  98,  100 

cold  compresses  in,  97,  100 

complications  in,  98,  100 

cough  in,  96,  99 

diagnosis  of,  94 

edema  of  larynx  in,  98,  100 

etiology  of,  94 

fomentations  in,  97,  100 

ice  collar  in,  97.  100 

in  epidemic  influenza,  256 

in  measles,  498,  508.  511 

in  small  pox,  615,  623 

in  typhus  fever,  630 

inhalations  in,  96,  98,  99 

local  treatment  of,  97,  99,  100 

rest  in,  95,  99 

smoking  prohibited  in,  95,  99 

sprays  in,  97,  100     • 

summary  of  treatment  of,  99 

symptomatology  of,  94 
Laryngoscope,  use  of,  94 
Latham,  on  chaulmoogra  oil  in  leprosy,  672 

on  lumbar  puncture,  573 
Lawson,  Mary  R.,  on  malaria,  328,  337 
Leeching.    See  Cupping 
Lees,  on  rheumatic  fever,  39,  54 
Leprolin,  for  leprosy,  674 
Leprosy,  670 

baths  in,  671 

Calmette's  antivenomous  serum  in,  673 

diet  in,  671,  676 

disposal  of  excreta  and  secretions  in,  670 

distribution  of,  670 

empirical  treatment  of,  671,  676 

fresh  air  in,  671,  676 

isolation  in,  670,  675 

local  treatment  of,  672,  676 

organism  of,  670 

precautions  for  attendants  in,  670,  675 
•    prognosis  of,  674 

prophylaxis  of,  674,  677 

specific  treatment  of,  673,  676 

summary  of  treatment  of,  675 

surgical  treatment  of,  674 

tonic  treatment  of,  674,  676 

X-ray  treatment  of,  674 

Leyden,  von,  on  gastro -intestinal  function,  18 
Light,  importance  of  in  treatment  of  septicemia, 

758 

Lillienthal's  method  of  aspiration,  254,  268 
Lindeman,  on  blood  transfusion  in  sepsis,  767 
Lipovaccines,  in  typhoid  fever,  309 
Liver  abscess,  in  amebic  dysentery,  378 
Lockjaw,  712 
Loeffler's  solution,  in  diphtheria,  466 

for  membranous  angina  in  scarlet  fever,  401 
Loewe,  on  blood  typing  in  pneumonia,  131 
Longcope,  on  serum  treatment  in  pneumonia,  130 
Lord,  on  fluid  in  chest  in  pneumonia,  180 

on  lung  expansion  in  pleurisy  with  effusion, 

124 
Losee,  on  blood  transfusion,  767 


Louse,  and  trench  fever,  751,  753 

and  typhus  fever,  624,  626 

Lovelace,  on  treatment  of  blackwater  fever,  344 
Lovett,  on  operative  treatment  in  poliomyelitis, 

602 
on  prevention  of  contracture  in  poliomyelitis, 

599 

Ludke,  on  pyrexia,  19 
Ludy,  on  anthrax,  681 
Lumbar  puncture,  for  cerebral  disturbances  in 

typhoid  fever,  298 
for  convulsions  in  pertussis,  536 
for  headache  in  scarlatinal  nephritis,  422 
in  cerebrospinal  meningitis,  569,  584 
amount  of  fluid  withdrawn,  571 
anesthetic  for,  570,  585 
appearance  of  fluid  in,  571 
bad  results  of,  573 
collecting  fluid  in,  571 
dry  tap  in,  572 
flow  in,  571 
needle  for,  570 
position  of  patient  in,  570 
preparations  for,  570 
reaction  in,  572 
site  of,  569 
the  tap  in,  571 

in  encephalitis  lethargica,  275 
in  meningitis  following  grip,  229 
in  meningo-encephalitis  of  mumps,  551 
Luminal,  for  restlessness  in  chorea,  60 
Lung,  abscess  of,  in  epidemic  influenza,  254 
complications  of  in  malaria,  337,  350 
expansion  in  pleurisy  with  effusion,  technique 

of,  124,  127 

Lusk,  on  infectious  fevers,  20 
on  functions  of  protein,  15 
Lyssophobia,  706 

MacCallum,  on  pyrexia,  19 

on  streptococcus  pneumonia,  208,  209 
Maclagan,  on  salicin,  37 

McCoflom,  method  of  fumigation  recommended 
by,  475 

on  dosage  of  diphtheria  antitoxin,  455 

on  irrigation,  in  nasal  diphtheria,  466 

on  laryngeal  diphtheria,  461 

on  scarlet  fever,  388,  402 

McCrae,  on  prophylaxis  of  typhoid  fever,  303 
McGlannan,  on  rabies,  701 
McGuire,  on  noma,  424,  429 
Macaroni,  food  value  of,  17 
Mackerel,  food  value  of,  17 
Magnesium  sulphate.    See  Epsom  salts 
Magnus-Levy,  on  metabolism,  12 
Malaria,  322 

algid  form  of.  336,  349 

anemia  in,  337,  350,  351 

bed  in,  323 

cachexia  in,  338,  350 

care  of  bowels  in,  324,  346 

carriers,  343 

chill  in,  324,  346 

choleraic  form  of,  336,  350 

classes  of,  322 

collapse  in,  325,  335 

complications  of,  336,  350 

convalescence  from,  340 

diet  in,  323,  346 

fever  in,  325,  346,  349 

headache  in,  325,  347 

hyperpyrexia  in,  325,  349 

isolation  in,  342 

latent,  338,  350 

masked,  338,  350 

multiple  infectious,  336 

nervous  manifestations  in,  339,  351 

pernicious,  330 

cerebrospinal  type  of,  335,  349 
collapse  in,  335 
comatose  form  of,  335,  349 
hyperpyrexia  in,  335 
irritative  form  of,  335,  349 
paralytic  form  of,  335,  349 


794 


INDEX 


Malaria,  pernicious,  quinine  treatment  of,  330, 

sequelae  of,  337,  350,. 

symptomatic  treatment  of,  335,  349 
prevention  of  collapse  in,  325,  346,  347 
prophylaxis  from,  340,  351,  342 
protection  of  individual  in,  341,  352 
relapses  in,  337,  350 
rest  in,  323,  345 
room  in,  323,  345 
sequete  of,  337,  350 
specific  treatment  of,  326,  346 
summary  of  treatment  of,  345 
sweating  in,  326,  347 
symptomatic  treatment  of,  during  paroxysm, 

324,346 

vomiting  in,  325,  346 

Malignant  pustule,  678,  679,  684,  and  see  An- 
thrax 

Mallein,  use  of  in  farcy,  688 
Malta  fever,  656 
bed  in,  657,  661 
care  of  body  in,  657,  661 

of  bowels  in,  658,  661 

of  joints  in,  658 
carriers  of,  660 
constipation  in,  658 
convalescence  from,  660,  663 
diet  in,  657,  661 
disinfection  in,  660 
disposal  of  excreta  in,  660 
distribution  of,  660 
drinks  in,  658 
fever  in,  659,  662 
goats  carriers  of,  656 
hyperpyrexia  in,  659 
incubation  period  of,  656 
orchitis  in,  660 
pain  in,  658,  662 
precautions  of  nurse  in,  657,  661 

of  physician  in,  657,  661 
prognosis  in,  660 
prophylaxis  of,  660,  663 
relapses  in,  657 
rest  in,  657,  661 
retention  of  urine  in,  658,  662 
room  in,  657,  661 
sleeplessness  in,  659,  662 
specific  treatment  of,  658 
summary  of  treatment  of,  661 
symptomatic  treatment  of,  658,  662 
symptoms  of,  656 
toxemia  in,  659,  662 
vomiting  in,  659,  662 

Mammary  gland  involvement  in  mumps,  550 
Mania,  from  salicylates,  40 
Manson,  theory  on  malaria,  329 
Mask,  for  physician  and  nurses  in  influenza,  241 
Mattresses,  disinfection  of,  282 
Maxwell  and  Pope,  on  ice  poultice  in  mumps,  549 
on  mustard  bath,  95 
on  hot  air  bath,  418 
Measles,  487 

adenitis  complicating,  499 

bath  in,  490,  504 

bed  in,  490,  504 

bronchitis  complicating,  498,  508 

bronchopneumonia  complicating,  495,  507 

care  of  bowels  in,  493,  498,  505 

of  cardiovascular  system  in,  494,  498 

of  eyes  in,  492,  501,  503,  505,  510 

of  genitals  in,  493,  505 

of  mouth  in,  492 

of  nose  in,  492,  505 

of  patient  in,  490,  504 

of  skin  in,  491,  505 
complications  of,  495,  507 
convalescence  from,  502,  511 
cough  in,  497 
diet  in,  490,  496,  504 
diphtheria  complicating,  501,  510 
disinfection  in,  503,  511 
distribution  of  family  in,  488,  503 
fresh  air  in,  489,  503 


gastro-intestinal  complications  of,  499,  509 
German,  512,  and  see  Rubella 
heart  complications  of,  501,  510 
ileocolitis  complicating,  500,  509 
infectivity  of,  487 
kidney  involvement  in,  501,  510 
laryngitis  complicating,  498,  508,  511   »• 
mortality  in,  487 
noma  complicating,  499,  509 
open  air  treatment  of,  496 
otitis  complicating,  499,  508 
photophobia  complicating,  501,  510 
precautions  in  sick  room  in,  490,  504 
of  nurse  in,  489,  503 
of  physician  in,  490,  504 
quarantine  in,  488,  502,  511 
room  in,  488,  503 
sleeplessness  in,  495,  507 
summary  of  treatment  of,  503 
treatment  of  fever  in,  493,  497,  506 
of  nervous  symptoms  in,  494,  506 
of  respiratory  failure  in,  494 
tuberculosis  complicating,  502,  511 
ulcerative  stomatitis  complicating,  499,  509 
water  in,  491,  504 
Medinal,  in  pneumonia,  169 
Meltzer,  on  magnesium  sulphate  as  a  test  for 

typhoid  carriers,  305 
on  magnesium  sulphate  in  tetanus,  720 
Meningismus,  in  epidemic  influenza,  269 

in  typhoid  fever,  302 
Meningitis,  cerebrospinal,  560,  and  see  Cerebro- 

spinal  meningitis 

Meningococcic    serum,   in   cerebrospinal   menin- 
gitis, 567 
dosage  of,  568 
early  use  of,  573 

intradural  administration  of,  569 
intravenous  administration  of,  574 
mode  of  preparation  of,  568 
results  of,  573 

Meningo-encephalitis  in  mumps,  550 
Mental  rest,  importance  of  in  febrile  conditions,  2 
Menthol,  in  bronchitis,  105,  109 
in  epidemic  influenza,  243 
in  pertussis,  528 
in  Malta  fever,  658 
in  small  pox,  612 

Methyl  sahcylate.    See  Salicylates 
Methylene  blue,  as  a  substitute  for  quinine,  339, 

351 
Meyer  and  Gottlieb,  on  caffeine  in  vasomotor 

weakness,  405 
Milk,  analysis  of,  16,  28 
in  acute  infectious  diseases,  16,  and  see  under 

the  several  diseases  (diet) 
caloric  value  of,  16,  35 
food  value  of,  17 

Milk  supply,  typhoid  fever  and,'JJ04 
Miller,  on  acidosis,  46 

Morphine,  for  choleraic  form  of  malaria,  336 
for  convulsions  in  anthrax,  684 
in  pertussis,  536 
in  rabies,  706 

in  scarlatinal  nephritis,  422 
in  septicemia,  761 
for  cough,  in  bronchitis,  106,  110 
in  glanders,  689 
in  laryngitis,  96,  99 
in  pneumonia,  166 
for  delirium,  in  anthrax,  684 
in  epidemic  influenza,*246 
in  erysipelas,  774 
in  infectious  jaundice,  733 
in  measles,  495 
in  pneumonia,  168 
in  scarlet  fever,  407 
in  septicemia,  761 
in  small  pox,  614 
in  typhus  fever,  629 
for  gastric  distress,  in  yellow  fever,  739 
for  headache,  in  dengue,  642 
in  malaria,  325 
in  pneumonia,  170 


INDEX 


795 


Morphine,  for  hemorrhage,  in  typhoid  fever,  296 
for  ileocolitis  complicating  measles,  501 
for  insomnia,  in  anthrax,  684 

in  epidemic  influenza,  246 

in  plague,  636 

in  pneumonia,  169 

in  Rocky  mountain  spotted  fever,  666 

in  small  pox,  615 

in  tonsillitis,  84,  89 

in  typhoid  fever,  298 

for  late  circulatory  failure,  in  diphtheria,  469 
for  pain,  in  dengue,  642 

in  epidemic  influenza,  245 

in  mumps,  551 
for  restlessness,  in  chorea,  61 
for  vomiting,  in  cholera,  648 

in  infectious  jaundice,  730 

in  malaria,  325 

in  Malta  fever,  659 
in  cerebrospinal  meningitis,  566 
in  encephalitis  lethargica,  275 
in  fibrinous  pleurisy,  118,  126 
in  poliomyelitis,  596 
in  rheumatism,  46,  53,  61 
in  trench  fever,  752,  755 
to  facilitate  nasal  feeding,  in  tetanus,  719 
Morphine  suppository,  for  tenesmus  in  bacillary 

dysentery,  364,  372 
Mpser  serum,  in  scarlet  fever,  409 

in  septicemia,  765 
Mosquito,  and  dengue,  641 
and  malaria,  322 
and  yellow  fever,  735 
destruction  of,  in  prevention  of  malaria,  341 

in  prevention  of  yellow  fever,  740 
Mouth,  care  of.    See  under  the  several  rtinnaitu 
Mumps,  545 
arthritis  in,  551 
baths  in,  546,  552 
care  of  bowels  in,  547,  552 

of  mouth  in,  546,  552 

of  nose  in,  546,  552 

of  patient  in,  546,  551 

of  secretions  in,  546 
complications  of,  549,  553 
convalescence  from,  551,  554 
disinfection  after,  551,  554 
diet  in,  546,  552 

distribution  of  family  in,  545,  551 
drugs  in,  548 
fever  in.  547,  552 
gland  involvement  in,  549,  552 
in  adults,  546 
incubation  period  of,  545 
infection  through  third  person,  546 
local  treatment  in,  547 
meningo-encephalitis  in,  550,  554 
nephritis  in,  551 
nervousness  in,  551,  554 
orchitis  complicating,  549,  553 
pain  in,  551,  554 
pancreatitis  in,  550,  553 
precautions  of  nurse  in,  546,  552 

of  physician  in,  546,  552 
release  from  quarantine  in,  551,  554 
room  in,  546,  551 
sleeplessness  in,  551,  554 
summary  of  treatment  of,  551 
symptoms  of,  545 
thrums  gland  in,  550 
treatment  of  parotitis  in,"  547,  552 
vulvitis  complicating,  550,^553 
Murphy  drip,  154 
apparatus,  153,  154 
in    bronchopneumonia    complicating    measles, 

498 

in  cholera,  648 
in  diphtheria,  451 
in  pneumonia,  154 
in  septicemia,  761 
in  yellow  fever,  739 
Mustard  bath,  for  convulsions  of  pertussis,  535 

in  laryngitis,  95,  99 

in  measles,  493 


Mustard  bath,  technique,  535 
footbath,  hot,  for  headache  in  yellow  fever,  738 
in  laryngitis,  95,  99 
in  rhinitis,  72 

pack,  for  convulsions  in  pertussis,  535 
pastes,  plasters,  and  poultices,  for  backache  in 

yellow  fever,  738 
for  bronchitis,  104,  109 
for  bronchitis  complicating  measles,  498 
for  bronchopneumonia  complicating  measles, 

493,  497 

for  cough  in  pleurisy,  162 
for  epidemic  influenza,  246,  251 
for  fibrinous  pleurisy,  116,  126 
for  gastric  distress  in  yellow  fever,  738 
for  nausea  in  cerebrospinal  meningitis,  565 
for  nausea  in  infectious  jaundice,  730 
for  nausea  in  scarlet  fever,  422 
for  vomiting,  in  malaria,  325 
in  Malta  fever,  659 
in  septicemia,  761 
in  typhoid  fever,  295,  315 
in  fibnnous  pleurisy,  116,  126 
in  pneumonia,  162,  187 
Mustard  plaster,  application  of,  163 
Muzzling  law,  for  prevention  of  rabies,  707 
Myositis,  in  scarlet  fever,  414 

Nagele  method  of  breaking  spasm  in  pertussis, 

528 

Nasal  diphtheria,  451,  and  see  Diphtheria,  nasal 
Nasal  feeding,  in  tetanus,  713,  724 
Nasal  hemorrhages  in  pertussis,  534 
Nasal  passages,  care  of  in  prophylaxis  of  pneu- 
monia, 192 
Nasopharynx,  care  of  in  pneumonia,  149 

portal  of  entry  of  bacillus  leprae,  670 
Nastin,  in  leprosy,  673 
Nausea.    See  under  the  several  diseases 
Negri  bodies,  in  rabies,  699 
Nephritis,  in  diphtheria,  473,  484 


in  epidemic  influenza,  258 
in  glai 


_  glandular  fever,  556 

in  infectious  jaundice,  731 

in  measles,  501 

in  mumps,  551 

in  scarlet  fever,  388,  414 

in  tonsillitis,  86 

Nervousness,  in  epidemic  influenza,  265 
Neuritis,  following  influenza,  259 
Nightgown,  special,  in  rheumatism,  32 

in  scarlet  fever,  392 
Nitrate  of  silver,  in  amebic  dysentery,  383 

in  bacillary  dysentery,  367 

for  ulcerative  somatitis  complicating  measles, 
500 

for  wound  in  rabies,  701 

Nitric  acid,  for  noma  complicating  scarlet  fever, 
424 

for  noma  complicating  measles,  500 

for  wound  in  rabies,  700,  708 
Nitrogen,  elimination  of,  21 

partition,  21 

rest,  24 

role  of,  in  acute  infectious  diseases,  21 

total,  22 

Nitroglycerin,     in     convulsions     in     scarlatinal 
nephritis,  422 

in  pneumonia,  177 
Noguchi,  on  yellow  fever,  735 
Noma,  complicating  measles,  499,  509 

in  scarlet  fever,  424 
Norris,  on  fluid  in  chest  in  pneumonia,  180 

on  pericarditis  in  pneumonia,  184 
Normal  salt  solution.    See  Saline  solution 
Northrup's  directions  for  release  of  scarlet  fever 

patient,  442 
Nose,  care  of.     See  under  the  several  diseases 

(nose,  or  body,  or  patient) 
Nose-bleed,  in  dengue,  643 

in  diphtheria,  467,  482 

in  pertussis,  534 

Nurse.     See  under  the  several  diseases 
Nux  vomica.    See  Strychnine 


796 


INDEX 


Oatmeal,  food  value  of,  17 
Odor  of  small  pox,  613,  622 
Oil,  food  value  of,  18" 

Oil  of  chenopodium,  for  amebic  dysentery,  383 
Oil  of  gaultheria,  43 
Oil  of  wintergreen,  43 
Oleum  betuhe,  43 
Oleum  gynocardise,  in  leprosy,  671 
Open  air  treatment,  of  bronchopneumonia  com- 
plicating measles,  496 
of  bronchopneumonia   complicating  pertussis, 

534 

of  diphtheria,  471 
of  fever,  4 
of  measles,  496 
of  pneumonia,  155,  168,  199 
of  typhoid  fever,  279 
of  typhus  fever,  630,  632 
Ophthalmoscope,  use  of,  94 
Opium 

in  anthrax,  684 

in  bacillary  dysentery,  363,  365,  372,  373 
in  cholera,  647.  654 
in  foot  and  mouth  diseases,  695 
in  ileocolitis  complicating  measles,  501 
in  infectious  jaundice,  730 
in  pertussis,  531,  536,  543,  641, 
in  typhoid  fever,  294 
Orchitis,  in  Malta  fever,  660 

in  mumps,  549,  553 
Otitis.    See  under  the  several  diseases 
Otoscope,  use  of,  94 

Ottenberg  and  Libman,  on  blood  transfusion,  767 
Ouabain,  in  pneumonia,  174 
Ovaries,  involvement  of  in  mumps,  550 
Oxygen    inhalations,    in    bronchopneumonia    of 

measles,  497 

in  convulsions  of  pertussis,  536 
in  dyspnea  of  pneumonia,  179 
in  poliomyelitis,  600 
in  pulmonary  edema  of  epidemic  influenza,  249 

Packs,  cold,  in  bronchopneumonia  complicating 

measles,  497 
in  measles,  493 
in  pneumonia,  161 
in  typhoid  fever,  291 

hot,  for  backache  in  yellow  fever,  738 
in  chorea,  60 

mustard,  for  convulsions  in  pertussis,  535 
Pain,     See  under  the  several  diseases 
Pancarditis,  in  rheumatism,  54 
Pancreas,  involvement  of  in  mumps,  550 
Paquelin  cautery,  in  noma  complicating  measles, 

499 

Paracentesis,     for    hydrothorax,     in    scarlatinal 
nephritis,  421 

for  pericarditis  of  pneumonia,  184 

in  mastoiditis  complicating  grip,  226 

in  otitis  complicating  scarlet  fever,  410 

of  knee  joint,  51 

Paraldehyde,  for  sleeplessness  in  pneumonia,  170 
Paralysis.     See  under  the  several  diseases 

infantile,  590,  and  see  Poliomyelitis 
Paratyphoid  fever,  320 

preventive  inoculation,  320 

treatment  of,  321 
Paregoric,  in  cholera,  647 

in  pertussis,  531,  541 
Park,  on  diptheria  antitoxin,  454.  456,  460 

on  rabies,  702,  703,  705 

on  tetanus  antitoxin,  715,  716,  717 

on  vaccine  therapy  in  farcy,  688 
Parotitis,  545,  and  see  Mumps 

complicating  pneumonia,  191 

complicating  typhus  fever,  630,  633 

in  epidemic  influenza,  260 

in  glandular  fever,  556 

treatment  of  in  mumps,  547,  552 
Parrots,  psittacosis  and,  698 
Pasteur  treatment  of  rabies,  703 
Patient,  care  of,  see  under  the  several  diseases 
Payne,  on  specific  organism  of  rheumatism,  30 
Peas,  food  value  of,  18 


Pediculus  vestimenti,  typhus  fever  transmitted 

by,  624 

Pembrey,  on  respiratory  exchange,  4 
Peptonized  milk,  enema  in  tetanus,  713 
Perforation  in  typhoid  fever,  297 
Pericarditis,  in  measles,  501 
in  pneumonia-,  184 
in  rheumatism,  53 
in  scarlet  fever,  423 

Perinephritic  abscess,  in  epidemic  influenza,  258 
Peritonsillar  abscess,  86 

Pernicious  malaria,  335,  and  see  Malaria,  per- 
nicious 
Pertussis,  520 

abdominal  support  in,  526,  533 
avoidance  of  emotional  states  in,  527 
bacillus  of,  520,  532 
baths  in,  524,  539 
bed  in,  524,  539 
bromides  in,  531.  536,  541 
bromoform  in,  532 
bronchopneumonia  in,  534 
care  of  bowels  in,  525,  539 
patient  in,  525,  539 
secretions  in,  523 
carriers  of  infection  of,  522 
catarrhal  stage  of,  520 

change  of  climate  in  convalescence  from,  543 
chloroform  for  paroxysms  of,  535 
clothing  in,  523,  538 
complement  fixation  test  in,  521 
complications  of,  533,  542 
contagiousness  of,  520 
convalescence  from,  536,  543 
convulsions  in,  535,  542 
cough  in,  525,  540 
diarrhea  in,  534,  542 
diet  in,  524,  539 
disinfection  of  room  in,  522 
distribution  of  family  in,  521,  537 
drugs  in,  528,  540 
elastic  belt  in,  526 
fever  in,  525,  539 
fixation  test  in,  521 
fresh  air  in,  537,  538 
hemorrhages  in,  534,  542 
hygiene  in,  525,  539,  544 
hyperexcitability  of  larynx  in,  528 
incubation  period  of,  520 
inhalations  in,  527 
insomnia  in,  533,  541 
intubation  in,  528 
isolation  in,  521,  537 
laryngeal  spasm  in,  528 
local  procedures  in,  526 
mechanical  support  in,  526 
mode  of  infection  in,  522 
mortality  in,  520 
nose  bleed  in,  534,  542 
open  air  treatment  of,  522,  538 
precautions  in  sick  room  in,  523,  538 
of  nurse  in,  523,  538 
of  physician  in,  523,  538 
prophylactic  use  of  vaccine  in,  523,  538,  544 
prophylaxis  of,  537 
quarantine  in,  536 
release  from  quarantine  in,  536,  543 
removal  of  adenoids  in,  537 
removal  of  tonsils  in,  537 
room  in,  522,  538 
sera  in,  532 

specific  treatment  of,  532 
summary  of  treatment  of,  537 
symptomatology  of,  521 
tonics  in  convalescence  from  537,  543 
treatment  of  severe  cases,  526,  540 
ulcer  of  frenum  in,  534,  542 
vaccines  in,  532 
vomiting  in,  520,  521,  533 
Pestis  minor,  634 

Pharyngeal  diphtheria,  antitoxin  in,  455 
Pharyngeal  paralysis  in  diphtheria,  451,  472 
Pharyngitis,  in  epidemic  influenza,  256 
in  poliomyelitis,  597 


INDEX 


797 


Phenacetin,  chemistry  of,  222 

in  bronchitis,  104,  109 

in  coryza,  72 

in  epidemic  influenza,  245 

in  erysipelas,  774 

in  fibrinous  pleurisy,  118,  126 

in  glandular  fever,  556 

in  grip,  218,  231 

in  Malta  fever,  659 

in  measles,  495,  498 

in  mumps,  547 

in  pneumonia,  161 

in  poliomyelitis,  596 

in  rheumatism,  45 

in  rhinitis,  72,  76 

in  scarlatinal  nephritis,  422 

in  scarlet  fever,  407 

in  small  pox,  614 

in  tonsillitis,  83,  89 

in  trench  fever,  752,  754 

toxic  effects  of,  223 
Phenol,  for  itching  in  scarlet  fever,  395 

for  itching  in  small  pox,  613 

for  itching  in  varicella,  516 

for  noma  complicating  measles,  500 

for  otitis  complicating  measles,  499 

for  wound  in  rabies,  701,  708 

in  anthrax,  679,  680,  681 

in  earache  of  scarlet  fever,  411 

in  farcy,  689 

in  measles,  492,  505 

in  tetanus,  718,  722 
Phenylsalicylate.    See  Salol 
Phlebitis,  in  epidemic  influenza,  257 

in  typhoid  fever,  302 

Photophobia  complicating  measles,  501,  510 
Phthalein  test  of  renal  function,  415 
Physician,  precautions  of.    See  under  the  several 


Physiological  salt  solution.    See  Saline  solution 

in  diphtheria,  466 

in  rabies,  701 

Physostigma,  for  convulsions  of  tetanus,  721 
Physostigmine,  for  tympanites  in  typhoid  fever, 

294 

Pilocarpine,  in  scarlatinal  nephritis,  419 
Pituitrin,  in  pneumonia,  152 

in  pneumonia  of  epidemic  influenza,  248 

in  tympanites  of  epidemic  influenza,  251 

in  tympanites  of  typhoid  fever,  294 
Plague,  634 

abortive,  634 

ambulatory,  634 

bed  in,  635,  638 

buboes  in,  636,  63H 

bubonic,  634 

care  of  bladder  in,  635,  639 
of  body  in,  635 
of  bowels  in,  635,  639 
of  patient  in,  635,  638 

carriers,  634 

circulation  in,  635 

convalescence  from,  637,  640 

delirium  in,  636,  639 

diarrhea  in,  636,  640 

diet  in,  635,  639 

disinfection  in,  637 

disposal  of  excreta  in,  635 

fever  in,  635,  639 

fulminating,  634 

headache  in,  636 

immunization  in,  638 

intestinal,  634 

isolation  in,  634 

nervous  symptoms  of,  636,  639 

organism  of,  634 

pneumonic,  634 

precautions  for  nurse  in,  635,  638 
for  physician  in,  635,  638 

prophylactic  inoculation  against,  638 

prophylaxis  of,  637,  638 

room  in,  634,  638 

role  of  rats  and  fleas  in,  637 

septicemic,  634 


Plague,  sequelae  of,  637 
sleeplessness  in,  636,  639 
serum  treatment  of,  636 
specific  treatment  of,  636 
summary  of  treatment  of,  638 
Pleurisy,  112 
dry,  112,  125 
types  of,  112 
Pleurisy,  fibrinous,  112 
blisters  in,  116,  126 
care  of  bowels  in,  114,  125 
cautery  in,  116,  126 
coal-tar  preparations  in,  118,  126 
cough  in,  113,  118,  126 
counterirritants  in,  116,  126 
cupping  in,  117 
diet  in,  113,  125 
drinks  in,  114,  125 
drugs  in,  117,  126 
dyspnea  in,  118,  126 
electric  pad  in,  115,  126 
fomentations  in,  115,  126 
heat  in,  115,  126 
hot  water  bag,  115,  126 
ice  bag  in,  115,  126 
iodine  in,  116,  126 
local  measures  in,  114,  126 
mustard  in,  116,  126 
pain  in,  113 
poultice  in,  116,  126 
room  in,  113,  125 
strapping  the  chest  in,  114,  126 
summary  of  treatment  of,  125 
Pleurisy,  purulent.    See  Empyema 
Pleurisy  with  effusion,  118 
after-treatment  of,  125,  127 
aspiration  in,  120,  127 
autoserotherapy  in,  124 
convalescence  in,  124,  127 
Delafield's  method  in,  119,  126 
diuretics  in,  123.  127 
expanding  lung  in,  124 
•exploratory  puncture  in,  120,  127 
general  care  of,  119,  126 
summary  of  treatment  of,  126 
thoracentesis  in,  119 
treatment  of,  119 
Pleuritis,  112,  and  see  Pleurisy 
Pneumococcus,  carriers,  193 

serum,  130,  and  see  Serum  treatment  in  pneu- 
monia 

types  of,  129 

vaccines,  prophylactic  use  of,  193 
Pneumonia,  lobar,  128,  and  see  Peumonia  (Pneu- 
mococcus) 

Pneumonia  (Pneumococcus),  128 
abdominal  pain  in,  191 
agglutination  test  in,  130 
anaphylaxis  in,  134,  145 
arthritis  in,  191 
bath  in,  147 
bed  in,  146,  155,  195 
bronchitis  in,  164 
bronchopneumonia,  in,  179 
care  of  body  in,  147,  197 

of  bowels  in,  151,  198 

of  circulation  in,  170,  203 

of  ears  in,  149 

of  eyes  in,  149 

of  fissures  in,  149 

of  genitals  in,  149 

of  mouth  in,  148 

of  nose  in,  149 

of  teeth  in,  148, 

of  tongue  in,  148 
carriers  of,  193 
collapse  in,  177,  204 
complications  of,  180,  205 
convalescence  from,  192,  20o 
cough  in,  161,  200 
desensitization  in,  135,  136 
diet  in,  149,  197 
drinks  in,  151,  198 
drugs  in,  161,  166,  168,  200 


798 


INDEX 


Pneumonia,  dyspnea  in,  179,  205 
embolism  complicating,  190 
empyema  complicating,  181,  187 
enemata  in,  152 
endocarditis  in,  190 
etiology  of,  128 
fever  in,  161,  200 

following  influenza,  226,  233,  236,  239,  246,  266 
fluid  in  chest  in,  180 
herpetic  eruption  in,  149 
hydro  therapy  in,  157 
in  cerebrospinal  meningitis,  588 
in  grip,  226,  233 
in  rheumatism,  68 
inhalations  in,  165,  201 
jaundice  in,  191 
local  treatment  of,  167 
meningitis  complicating,  191 
Murphy  drip  in,  154 
open  air  treatment  of,  155,  168,  199 
pain  in,  166 

parotitis  complicating,  191 
pericarditis  complicating,  184,  205 
peritonitis  complicating,  191 
pleurisy  in,  161 
prophylaxis  of,  192 
relapses  in,  191 
rest  in,  146,  194 
room  in,  147,  195 
sensitization  in,  134,  135 

serum  treatment  of,  130,  and  see  Serum  treat- 
ment of  Pneumonia 
specific  treatment  of,  129,  195 
summary  of  treatment  of,  194 
symptomatic  treatment  of,  155,  160,  200 
toxemia  in,  167,  201 
treatment  of  collapse  in,  177,  204 

of  cough  in,  161 

of  delirium  in,  168,  201 

of  dyspnea  in,  179,  205 

of  fever  in,  161,  200 

of  headache  in,  170,  202 

of  pulmonary  edema  in,  178,  205 

of  sleeplessness  and  restlessness  in,  169,  202 

of  toxemia  in,  201 
tympanites  in,  152,  199 
types  of,  128,  129 
use  of  rectal  tubes  in,  152 
vaccines,  193 

Pneumonia  (Streptococcus),  208 
empyema  in,  209 
pathology  of,  208,  210 
summary  of  treatment  of,  215 
symptomatology  of,  210 
treatment  of,  210 
Poliomyelitis,  590 
abortive  cases  of,  591 
active  movements  in,  601 
bed  in,  593,  603 
bulbospinal  type  of,  599,  606 
care  of  bladder  in,  594,  604 

of  bowels  in,  594,  604 

of  patient  in,  592,  593,  603 
carriers  of,  590 
cerebrospinal  fluid  in,  591 
contractures  in,  599,  602 
convulsions  in,  596,  605 
diarrhea  in,  597,  606 
diet  in,  593,  604 
disinfection  in,  592 

gastrointestinal  symptoms  in,  596,  606 
hyperesthesia  in,  605 
insomnia  in,  596,  605 

involvement    of    muscles    of    trunk    and    dia- 
phragm in,  600 
isolation  in,  592,  603 
meningo-encephalitic  type  of,  598 
operative  treatment  of,  602 
paralysis  of  extremities  in,  600,  606 
paralytic  period  of,  600,  606 
passive  movements  in,  601 
pathology  of,  597 
pharyngitis  in,  606 
precautions  of  nurses  in,  592 


Poliomyelitis,  precautions  of  physicians  in,  592 

preparalytic  period  in,  594,  604 

prognosis  of,1 602 

prophylaxis  of,  607 

protection  of  community  in,  590 

room  in,  592,  603 

serum  treatment  of,  594,  595,  604,  605 

specific  treatment  of,  594 

summary  of  treatment  of,  603 

symptomatic  treatment  of,  593,  604 
tonsillitis  in,  606 

transmission  of,  590,  592 

types  of,  597 

unne  in,  594,  604 
Pope  and  Maxwell,  on  hot  air  bath,  418 

on  ice  poultice  in  mumps,  549 

on  mustard  bath,  95 

Potassium  chlorate,  in  foot  and  mouth  disease, 
695 

for  gargling  in  small  pox,  611 

for  ulcerative  stomatitis  complicating  measles, 

499 

Potassium  iodide,  in  rheumatism,  46 
Potassium  permanganate,  for  membranous  angina 
in  scarlet  fever,  401 

for  noma  complicating  measles,  500 

for  sterilization,  475 

in  cholera,  648 

in  diphtheria,  466 

in  foot  and  mouth  disease,  695 

in  glanders,  689 

in  small  pox,  611 

Potassium  salts,  for  nervous  symptoms  of  sep- 
ticemia,  761 

in  nephritis  of  scarlet  fever,  420 
Potato,  food  value  of,  17 
Poultices,  in  adenitis  of  scarlet  fever,  413 

dry,  for  orchitis  in  mumps,  549 

hot,  in  anthrax,  681 
in  cholera,  647 
in  dengue,  642 

in  fibrinous  pleurisy,  116,  126 
in  pericarditis  of  pneumonia,  186 
in  pneumonia,  163 
in  scarlatinal  nephritis,  420 

ice,  in  mumps,  548 

in  bacillary  dysentery,  362 

in  bronchitis,  condemned,  105 
Poynton   and   Payne,   on   specific   organism   of 

rheumatism,  51 

Precipitation  method,  in  pneumonia,  130 
Pregnancy,  use  of  quinine  during,  334 
Premature  systole,   in  epidemic  influenza,   257, 

268     ' 

Pressure,  in  local  treatment  of  rheumatism,  51 
Proescher,  on  rabies,  704 
Prophylaxis.    See  under  the  several  diseases 
Protargol,  in  amebic  dysentery,  382,  386 
Protein,  amount  necessary  to  replace  wear  and 
tear,  15 

amount  needed  in  fever,  3 

amount  needed  in  health,  3 

amount  needed  in  infectious  diseases,  28 

amount  needed  in  typhoid  fever,  282 

assimilation  of,  in  acute  infectious  diseases,  18 

destruction  of  by  fever,  20 

functions  of,  14,  28 

percentage  of,  in  milk,  17 

needs,  14,  28 

source  of  heat,  15 

toxic  destruction  of,  20 
Protein  therapy,  foreign,  in  rheumatism,  58 
Psittacosis,  698 

prognosis  of,  698 

prophylaxis  of,  698 

summary  of  treatment  of,  698 
Psychasthenia,  in  epidemic  influenza,  259 
Psychoses,  in  epidemic  influenza,  266 
Puerperal  sepsis,  765 

Pulmonary  complications,  in  rheumatism,  56,  58 
Pulmonary  edema,  in  epidemic  influenza,  248 

in  pneumonia,  178 

Pulmonary  embolism,  complicating  pneumonia, 
192 


INDEX 


799 


Pulmonary  exercises,  following  pneumonia,   192 
Pulse,  in  typhoid  fever,  effect  of  baths  on,  290 
Purgation,  in  scarlatinal  nephritis,  417 
Purpuras,  in  rheumatism,  57 
Pustule,  in  varicella,  516 

malignant  of  anthrax,  678 
Pyelitis,  in  cerebrospinal  meningitis,  578 
Pyelonephritis,  in  epidemic  influenza,  258,  269 
Pyemia,  757,  and  see  Septicemia 

abscesses  in,  763 

in  erysipelas,  777 

surgical  treatment  of  abscesses,  760 
Pylephlebitis,  in  septicemia,  763 
Pyrexia,  19,  and  see  Fever,  and  under  the  several 
diseases 

destructive  action  on  protein,  20 

factor  in  feeding  in  infectious  diseases,  18 

factor  in  fever,  19 

increased  caloric  demand  in,  28 

significance  of,  3 

and  toxemia,  parallelism  of,  1 

Quarantine.    See  under  the  several  diseases 
Quigley,  on  typing  of  urine,  in  pneumonia,  132 
Quinine,  action  of,  326 

for  children,  329.  348 

contraindications  to,  334 

desensitization,  334 

dosage,  328 

fastness,  329 

hypodermic  use  of,  331,  348 

hypodermoclysis  with,  331 

idiosyncrasy  to,  334 

intramuscular  use  of,  331 

intravenous  administration  of,  332,  348 

immunity,  329 

preparations  of,  328 

prophylactic  use  of,  327,  342 

substitutes  for,  340,  351 

time  for  administration  of,  327 

toxic  effects  of,  333 
Quinine,  in  amebic  dysentery.  381 

in  black  water  fever,  344,  352 

in  bronchitis,  104 

in  diphtheria,  474,  485 

in  epidemic  influenza,  244 

in  grip,  224,  232 

in  malaria,  326  to  335  and  347  to  349 

in  pertussis,  532 

Rabies,  699 

confirmation  of  diagnosis  of,  701 

convulsive  paroxysms  of,  706,  709 

detention  of  dogs  for  prevention  of,  707 

diet  in.  709 

immunity  in,  699 

in  America,  708 

incubation  period  of,  699,  700 

licensing  of  dogs  for  prevention  of,  707 

maniacal  periods  in,  707,  710 

muzzling  law  for  prevention  of,  707 

Pasteur  treatment  of,  703 

preventive  treatment  of,  702 

procedures  in,  700 

prophylaxis  of,  707,  710 

quarantine  in,  707,  710 

results  of  preventive  treatment  in,  705 

room  in,  706,  709 

summary  of  treatment  of,  708 

stages  of,  706 

symptoms  of,  706 

in  dog,  702 
transmission  of,  699 
treatment  of,  at  a  distance,  704 

of  developed  disease,  706,  709 

of  old  bites,  709 

of  wound  in,  700,  708 
virus  of,  699 

Rash,  due  to  diphtheria  antitoxin,  458 
Rat-bite  fever,  744 
anemia  in,  748,  750 
bed  in,  746 
blood  picture  in,  745 
care  of  body  in,  746 


Rat-bite  fever,  care  of  bowels  in,  746,  748 
of  mouth  in,  746 
of  skin  in,  747,  749 

cause  of,  744 

circulation  in,  747,  749 

complications  of,  748 

convalescence  in,  748,  750 

delirium  in,  747,  749 

diet  in,  746,  748 

dizziness  in,  747,  749 

fever  in,  744,  747,  749 

fluids  in,  746,  748 

incubation  period  of,  744 

nephritis  in,  748 

nervousness  in,  747,  749 

pains  and  aches  in,  746,  749 

prophylaxis  in,  748,  750 

room  in,  746 

sleeplessness  in,  747,  749 

specific  treatment  of,  747,  749 

summary  of  treatment  of,  748 

symptomatology  of,  744 
Rats  and  plague,  634,  637 
Ravenel,  on  farcy,  689 
Rectal  administration  of  coffee,  in  pneumonia,  176 

of  digitalis,  172 

of  salicylates,  47,  66 
Rectal  feeding,  in  diphtheria,  451 

in  foot  and  mouth  disease,  694 

in  late  circulatory  failure  in  diphtheria,  469 

in  persistent  vomiting  in  septicemia,  761 

in  tetanus,  713 
Rectal  irrigations,  for  pain  in  bacillary  dysentery, 

363 

Rectal    tubes,    for   tympanites   in   epidemic   in- 
fluenza, 251 

for    tympanites    in    bronchopneumonia    com- 
plicating measles,  498 

for  tympanites  in  pneumonia,  152 

for  tympanites  in  typhoid  fever,  293 

disinfection  of,  281 

Renal  complications,  from  salicylates,  40 
Renal  function,  in  nephritis  of  scarlet  fever,  415 
Repair  of  wear  and  tear,  function  of  protein  in, 

14,28 

Resection  of  rib,  for  empyema,  188 
Resistance  exercises,  in  poliomyelitis,  601 
Respiration,  effects  of  cold  water  on,  5 

effects  of  baths  on,  in  typhoid  fever,  290 
Respiratory  disturbances,  from  salicylates,  40 
Respiratory  failure,  in  diphtheria,  472 

in  measles,  494 

in  poliomyelitis,  600 

Respiratory  symptoms,  in  small  pox,  615 
Respiratory  system,  care  of,  in  glanders  and  farcy, 

689 
Rest.    See  under  the  several  diseases 

calories  of  energy  in,  3 

caloric  requirements  of  man  in,  12 

in  febrile  conditions,  2,  8 

physiological  significance  of,  2 
Rest  nitrogen,  24 

Restlessness.    See  under  the  several  diseases 
Retinal  hemorrhages  from  salicylates,  40 

in  septicemia,  763 
Retropharyngeal     abscess,     differentiated     from 

diphtheria,  464 
Revaccination,  against  smallpox,  619 

against  typhoid  fever,  308 
Rheumatic  children,  63 

joints  of  infancy,  30 
Rheumatic  fever,  acute,  30 

acetanilid  in,  45 

acidosis  in,  46 

adenoids  in,  62 

age  in,  30 

alkaline  salts  in,  43 

alkaline  treatment  of,  46 

antipyrin  in,  45 

arrhythmia  in,  41 

arthritis  in,  48,  51 

aspirin  in,  42 

autoserotherapy  in,  61 

bed  in,  32,  63 


800 


INDEX 


Rheumatic  fever,  bowels  in,  35,  64 

bradycardia  in,  41 

cardiac  complications  in,  53,  55,  67,  68 

catharsis  in,  35 

chorea  and,  59 

complications  of,  52,  67 

convalescence  from,  61,  70 

counter-irritation  in,  50,  67 

delirium  in,  40,  53 

diagnosis  of,  in  infancy,  30 

diet  in,  33,  63 

drugs  to  relieve  pain,  66 

dyspnea  in,  40 

effusions  in,  67 

etiology  of,  30 

fluids  in,  35 

foreign  protein  therapy  in,  58 

hyperpyrexia  in,  52 

in  children,  30 

in  infancy,  30 

insomnia  in,  68 

intestinal  infection  and,  62 

intravenous  injection  of  foreign  protein  in,  58 

joints  in,  31,  48,  50,  51 

local  applications  in,  50,  67 

morphine  in,  46 

paracentesis  in,  51 

phenacetin  in,  45 

pressure  in,  51 

prophylaxis  in,  61,  70 

pulmonary  complications  in,  56,  58 

rest  in,  31,  48,  63 

room  in,  33,  63 

salicylates  in,  37,  64 

shock  therapy  in,  58 

sleep  in,  36,  68 

soapsuds  enema  in,  36 

specific  treatment  of,  37,  64 

summary  of  treatment  of,  63 

symptomatic  treatment  of,  48,  66 

symptomatology  of,  31 

teeth  in,  62 

theories  of,  30 

therapy  of,  31 

tonsils  in,  62 

vaccine  therapy  in,  57,  68 

water  in,  35 
Rheumatism,  30,  and  see  Rheumatic  fever,  acute 

scarlatinal,  413 
Rhinitis,  acute,  71 

abortive  treatment  of,  72 

aches  and  pains  in,  72,  76 

antral  involvement  in,  75,  79 

complications  of,  75,  78 

C9ugh  in,  75,  77 

direct  application  in,  73 

early  treatment  of,  72 

etiology  of,  71 

in  grip,  227,  233 

in  scarlet  fever,  402 

inhalations  in,  74,  77 

later  treatment  of,  74,  78 

local  treatment  of,  73,  77 

ointments  in,  73 

otitis  complicating,  75,  79 

personal  hygiene  in,  75,  79 

prophylaxis  of,  75,  79 

removal  of  obstructions  in,  75,  79 

sinusitis  complicating,  75,  79 

sore  throat  in,  75 

sprays  in,  73,  74,  77,  78 

summary  of  treatment  of,  76 

symptomatology  of,  71 
Rice,  on  anthrax,  681 
Rice,  food  value  of,  17 
Richter,  on  trench  fever,  753 
Ringer's  solution,  652 
Ringing  in  the  ears,  due  to  quinine,  333 
Roast  beef,  food  value  of,  17 
Rochelle  salts,  in  bronchitis,  103,  109 

in  cerebrospinal  meningitis,  565,  582 

in  dengue,  642 

in  diphtheria,  452 

in  epidemic  influenza,  243 


Rochelle  salts,  in  erysipelas,  774 

in  fibrinous  pleurisy,  114,  125 

in  grip,  217,^31 

in  ileocolitis"  complicating  measles,  501 

in  laryngitis,  95,  99 

in  Malta  fever,  658 

in  mumps,  547 

in  plague,  635 

in  pneumonia,  151 

in  rheumatism,  35 

in  scarlatinal  nephritis,  417 

in  scarlet  fever,  397 

in  septicemia,  and  pyemia,  760 

in  tonsillitis,  82,  88 

in  typhoid  fever,  292,  314 
Rocky  mountain  spotted  fever,  664 

aches  and  pains  in,  664,  668 

baths  in,  665 

bed  in,  665 

care  of  body  in,  665 
of  bowels  in,  666,  667 
of  eyes  in,  666 
of  genitals  in,  666 
of  mouth  in,  666 
of  nose  in,  666 
of  skin  in,  666 

cause  of,  664 

circulation  in,  667,  668 

complications  of,  667 

delirium  in,  666,  668 

desquamation  in,  665 

diet  in,  666,  667 

fever  in,  664,  666,  668 

fluids  in,  667 

headache  in,  668 

immune  serum  in,  667,  669 

incubation  period  of,  664 

insomnia  in,  666,  668 

prophylaxis  in,  667,  669 

pulse  in,  665 
'rash  in,  665 

room  in,  665 

summary  of  treatment  of,  667 

symptomatology  of,  664 

ticks  and,  664 
Rogers,  on  cholera,  647,  652 

on  dosage  of  quinine,  330 

on  emetine  treatment  in  amebic  dysentery,  377 
Room.    See  under  the  several  diseases 
Rosenau,  on  conveyance  of  smallpox,  608 

on  rabies,  701 

on  serum  treatment  in  pneumonia,  130 
Rosenow,  on  rheumatism,  63 

theory  of  etiology  of  rheumatism,  30 
Rost,  on  leprosy,  674 
Rowntree  and  Amberg,  on  creatininin  in  infants, 

23 

Rubber  sheets,  disinfection  of,  281 
Rubella,  512 

care  of  bowels  in  513 

complications  of,  514 

diet  in,  513 

isolation  in.  512 

summary  of  treatment  of,  513 
Rubner's  caloric  values,  13 
Rudolph,  on  hemorrhage  in  typhoid  fever,  295 
Riihrah,  on  small  pox,  612 

Russell,    technique   of    antityphoid   vaccination, 
307 

Salicin,  45,  and  see  Salicylates 

in  glandular  fever,  556 

in  grip,  224 

in  rheumatism,  37,  45 

in  scarlatinal  arthritis,  413 

in  tonsillitis,  83,  89 
Salicylates,  37 

in  anthrax,  683 

in  bronchitis,  104,  109 

in  cholera,  647 

in  chorea,  60 

in  dengue,  642 

in  epidemic  influenza,  244,  245,  265 

in  fibrinous  pleurisy,  117,  126 


INDEX 


801 


Salicylates,  in  grip,  232 

in  infectious  jaundice,  731 

in  Malta  fever,  658 

in  poliomyelitis,  596 

in  rheumatism,  37,  39,  43,  46,  60,  64 

in  scarlatinal  nephritis,  413,  420 

in  tonsillitis,  82,  89 
Salicylates,  acidosis  from,  46 

dyspnea  from,  40 

intravenous  administration  of,  47,  66 

rectal  administration  of,  47,  66 

synthetic,  42 

toxic  symptoms  of,  39 
Salicylic  acid,  37,  and  see  Salicylates 
Saline    infusions,    for    hemorrhage    in    typhoid 
fever,  297,  316 

in  uremia  in  scarlatinal  nephritis,  421 
Saline  irrigation,  for  collapse  in  pneumonia,  178 

for  diarrhea  in  typhoid  fever,  294 

in  poliomyelitis,  597 
Saline  rectal  injections,  for  renal  congestion  in 

yellow  fever,  739 
Saline  solution,  enteroclysis  of,  in  diphtheria,  470 

intravenous  injection  of,  in  cholera,  648 

irrigati9n  of  nose  with  in  glanders,  689 

oral  irrigation  with  in  foot  and  mouth  disease, 
694 

in  tetanus,  714 
Saline  treatment  of  bacillary  dysentery,  359,  362, 

372 

Salivary  secretion,  in  acute  infectious  diseases,  18 
Salmon,  food  value  of,  17 
Salt >I.  in  rheumatism,  45 
Salt-bag,  hot,  for  earache,  411 
Salt  solution,  as  mouth  wash  in  measles,  492 

in 


physiological,     for     membranous 

scarlet   fever,    400 
for  nose  in  scarlet  fever,  402 
Salts.     See  Epsom  salts,  and  Rochelle  salts 
caloric  value  of,  13 
excreted  by  intestines,  22 
Sanford,  on  blood  transfusion,  767 
Salvarean,  in  malaria,  340 
in  rat  bite  fever,  747,  749 
in  trench  fever,  753 
in  Vincent's  angina,  92,  93 
Sanitation,  in  prevention  of  typhoid  fever,  304 
Satterlee,  on  blood  transfusion,  767 
Scarlatinal  nephritis,  414 
Scarlatinal  rheumatism,  413 
Scarlet  fever,  387 
adenitis  in,  412,  437 
anemia  in,  423,  441 
angina  in,  398.  432 
arthritis  in,  413,  437 
bed  in,  392,  and  see  Pneumonia,  bed  in 
bronchopneumonia  complicating,  423 
cardiovascular  apparatus  in,  403 
care  of  bowels  in,  397,  431 
of  discharges  in,  392 
of  eyes  in,  431 
of  genitals  in,  397,  431 
of  mouth  in,  396,  430 
of  nose  in,  396,  402,  431 
of  skin  in,  395.  430 
of  teeth  in,  396 
of  throat  in,  396,  397,  431 
catharsis  in,  397 
causative  agent  in,  387 
circulatory  failure  in,  434 
contacts,  389 

convalescence  from  nephritis  in,  423,  441 
convulsions  in,  422,  440 
delirium  in,  407 
desquamation  in,  388.  430 
diaphoresis  in,  421,  438 
diet  in,  392,  416,  429,  438 
discharge  of  patient  after,  424,  441 
disinfection  of  utensils  in,  392,  428 
distribution  of  family  in,  388,  427 
diuresis  in,  420,  439 
drinks  in,  395.  416,  430 
earache  in,  411 
edema  in,  421,  438,  439 


Scarlet  fever,  eosinophilia  in,  388 

erythematous  eruption  in,  387 

exfoliation  in,  395 

fever  in,  397,  432 

fumigation  after,  425,  442 

headache  in,  422,  440 

heart  in,  423,  403 

hypertension  in,  439,  440 

immune  human  serum  in,  408 

incubation  period  of,  387,  427 

isolation  in.  390 

leucocytosis  in,  388 

muscular  twitching  in,  421,  439 

myocarditis  in,  423 

myositis  in,  414 

nausea  and  vomiting  in,  422,  431,  440 

nephritis  in,  388,  414,  437 

nervous  symptoms  in,  407,  435 

noma  complicating,  424,  441 

normal  human  blood  in,  409 

oliguria  in,  438 

onset  and  diagnosis  of,  387,  427 

otitis  in,  409,  436 

patient  in.  392,  428 

pericarditis  in,  423 

polyvalent  serum  from,  409 

precautions  in  sick  room  in,  391,  428 
of  nurse  in,  390,  428 
of  physician  in.  391,  428 

prophylaxis  in,  426 

protection  of  family  in.  388 

quarantine  in,  424,  425,  426,  and  see  Distri- 
bution of  family,  and  Isolation 

recurrence  of,  424 

relapses  in,  424,  441 

release  of  patient  after,  424 

restlessness  in,  407,  435 

rhinitis  in.  402,  433 

room  in,  389,  427 

septicemia  in,  764 

serum  therapy  in,  407,  436 

sleeplessness  in,  407,  435 

sore  throat  in.  387 

specific  treatment  of,  407,  436 

sterilization  after,  425,  442 

summary  of  treatment  of,  427 

suppression  of  urine  in,  438 

symptomatic  treatment  of,  397 

temperature  in,  387 

tongue  in,  388 

uremia  in,  421,  439 

use  of  cold  in  432 

vaccine  therapy  in,  402,  407,  411,  436 

vomiting  in,  397 

water  in,  395 

Schamberg,  on  iodine  in  small  pox,  613 
Schick  reaction,  in  diphtheria,  444,  445,  449,  450.' 
477 

combined  reaction,  447 

control,  447 

negative  reaction,  446 

pseudo-reaction,  446 

technique  of,  445 
Setter's  tablets  in  coryza,  73 

in  rhinitis.  73 

Sellard's  dosage  of  emetine  in  amebic  dysentery, 
377 

method  of  determining  acidosis,  251 

treatment  of  Asiatic  cholera,  648,  649.  651 
Sensitization,  in  pneumonia,  134 

determination  of,  135 
Septic  conditions,  physiology  of  diet  in,  3 
Septic  sore  throat,  in  tonsillitis,  85,  90 
Septicemia  and  Pyemia,  757 

accidents  after,  770 

arthritis  in,  763,  771 

bed  in,  759,  768 

blood  transfusion  in,  766 

care  of  body  in,  760 
of  bowels  in,  760,  769 

cerebrospinal  meningitis  in,  762 

chills  in,  760,  769 

circulation  in,  762,  770 

collapse  in,  760,  769 


802 


INDEX 


Septicemia    and    Pyemia,   convulsions   in,   762, 
770 

delirium  in,  761,  770 

diagnosis  of  in  early  stage,  758 

diet  in,  759,  768 

drugs  for  nervous  symptoms  of,  761 

early  symptoms  of,  758 

emboli  in,  763,  771 

erythema  in,  763 

fever  in,  760,  769 

fluids  in,  760,  769 

form  of  in  puerperal  sepsis,  765 
in  scarlet  fever,  764 

fresh  air  in,  759 

headache  in,  762,  770 

hemorrhages  in,  763 

hyperpyrexia,  in,  760 

icterus  in,  763 

in  erysipelas,  777 
-  in  nephritis,  86 

in  scarlet  fever,  764 

infarcts  in,  763,  771 

insomnia  in,  761,  770 

involvement  of  kidneys  in,  763,  771 

light  in,  758 

malignant  endocarditis  in,  762 

nervous  symptoms  in,  761,  770 

organisms  of,  757 

osteomyelitis  in,  763 

pneumococcus,  766 

polyvalent  serum  in,  765 

prophylaxis  of,  768 

rest  in,  758,  768 

restraint  of  patient  in,  761 

room  in,  758,  768 

specific  treatment  of,  764,  771 

staphylococcus,  757,  764,  766 

streptococcus,  757,  763 

summary  of  treatment  of,  768 

symptomatic  treatment  of,  760,  769 

sweats  in,  760 

thrombophlebitis  in,  762,  771 

vaccine  therapy  in,  765 

visceral  abscesses  in,  764 

vomiting  in,  760,  770 
Septicopyemia,  symptoms  of,  758 
Serum,  administration  of,  133,  195 

anaphylaxis  after,  134,  145 

apparatus,  137 

dosage,  146,  196 

injection  of,  142 

preparation  of  patient  and  operator,  141 

precautions,  136 

reaction  after,  143,  196 

shock  after,  145 

sterilizing  apparatus,  140 

symptoms  after,  144 
Serum  sickness,  pneumococcal,  196 
Serum  therapy.     See  under  the  various  diseases 
Shad,  food  value  of,  17 
Shaffer,  on  typhoid  diet,  22,  23,  25,  283 
Shattuck,  typhoid  diet,  285 
Shaving  brushes  and  anthrax,  678 
Sheet  bath,  technique  of,  159 
Shock,  anaphylactic,  in  pneumonia,  145 
Shock  therapy,  in  rheumatic  fever,  58 
Sick  room,  care  of.    See  under  the  several  diseases 
Silver  nitrate,  in  amebic  dysentery,  382 

in  bacillary  dysentery,  368 

for  oral  ulcers  in  smallpox,  611 

for  ulcerative  stomatitis  complicating  measles, 
500 

for  ulcer  of  frenum  in  pertussis,  534 

for  ulcers  of  mouth  in  foot  and  mouth  disease, 
695 

in  tonsillitis,  84,  89,  90 

in  Vincent's  angina,  92,  93 
Silver  preparations  for  carriers  of  cerebrospinal 

meningitis,  579 

Sino-auricular  block,  in  rheumatism,  41 
Sinus  arythmia,  in  epidemic  influenza,  257,  268 
Sinus  thrombosis  in  grip,  226,  233 
Sinuses,  involvement  of,  in  rheumatic  fever,  62 
in  scarlet  fever,  402 


Sinusitis,  complicating  coryza,  75 
epidemic  influenza,  256 
rhinitis,  75,  79 

Skatol,  in  undetermined  nitrogen,  25 
Skin,  care  of.    See  under  the  several  diseases  • 
Skin  eruptions,  complicating  rheumatism,  57 
due  to  antipyretics,  223 
due  to  quinine,  333 
due  to  salicylates,  40 
Sladen,  on  infectious  jaundice,  732 
Sleeplessness.    See  under  the  several  diseases 
Sleeping    sickness,    271,    and    see    Encephalitis 

lethargica 

Sliding  in  bed,  to  prevent,  147 
Slush,  in  typhoid  fever,  291 
Small  pox,  608 
baths  in,  611,  621 
bed  in,  610 

care  of  bowels  in,  613,  622 
of  eyes  in,  611,  621 
of  mouth  in,  610,  620 
of  nose  in,  611,  621 
of  skin  in,  611,  621 
delirium  in,  614,  623 
diet  in,  610,  620 
disinfection  in,  616 
fever  in,  614,  622 
headache  in,  614,  622 
initial  stage  of,  613 
insomnia  in,  614,  623 
isolation  in,  608,  620 
precautions  for  nurse  in,  609,  620 

for  physicians  in,  609,  620 
quarantine  in,  615,  624 
respiratory  symptoms  in,  615,  623 
room  in,  608 

summary  of  treatment  of,  620 
symptomatic  treatment  of,  613,  622 
treatment  of  other  members  of  family  or  ex- 
posed persons,  609,  612 
vaccination  against,  616 
water  in,  610 

Smith,  Theobald,  on  vaccine  therapy  in  farcy,  688 
Smoking  prohibited,  in  bronchitis,  102 

in  laryngitis,  95,  99 
Soapsuds  enema,  in  rheumatic  fever,  36 

technique  of,  36 

Sodium  benzoate  and  caffeine  in  febrile  condi- 
tions, 6 

in  Malta  fever,  660 
in  scarlet  fever,  405 
Sodium  bicarbonate,  for  nausea,  in  cerebrospina 

meningitis,  566 
in  scarlet  fever,  422 

for  laryngitis  complicating  measles,  499 
for  retching,  in  small  pox,  615 
for  vomiting,  in  anthrax,  683 

in  poliomyelitis,  596 
in  epidemic  influenza,  245 
in  infectious  jaundice,  730 
in  measles,  491 
in  scarlatinal  arthritis,  413 
in  scarlatinal  nephritis,  420 
in  typhoid  fever,  295 
spray,  for  membranous  angina  in  scarlet  fever, 

400 
Sodium  bromide,  in  laryngitis,  98,  100 

in  pertussis,  529 

Sodium  chloride  solution  in  cholera,  648 
for  irrigating  throat  in  diphtheria,  466 
Sodium  phosphate,  in  bronchitis,  103 
in  scarlatinal  nephritis,  417 
in  septicemia,  760 
in  tonsillitis,  82 

Sodium  potassium  tartrate.     See  Rochelle  salts 
Sodium  salicylate,  in  Malta  fever,  660 
in  scarlatinal  arthritis,  413 
in  scarlatinal  nephritis,  420 
in  scarlet  fever,  405 
solutions  of,  doses,  41 
synthetic,  42 
toxic  dose  of,  39 

Sodium  sulphate.    See  Glauber's  salts 
Soft  palate,  paralysis  of  in  diphtheria,  472 


INDEX 


803 


Sollman  on  caffeine  in  vasomotor  weakness,  405 
Sophian  on  cerebrospinal  meningitis,   568,   571, 

576,  579 
Sordes,  in  cerebrospinal  meningitis,  565 

in  diphtheria,  452 

in  measles,  492 

in  scarlet  fever,  396 

in  typhoid  fever,  280 
Sore  throat,  80,  and  see  Tonsillitis 

diphtheritic,  81 

in  coryza,  75 

in  rheumatism,  57,  68 

in  rhinitis,  75 

in  scarlet  fever,  387 
Southey  tubes,  421 
Sparteine,  in  pneumonia,  175 
Spasmodic  croup,   differentiated  from  laryngeal 
diphtheria,  464 

treatment  of,  98 
Specific     treatment.       See     under     the     several 

diseases 

Spinach,  food  value  of,  17 
Spinal  fluid,  in  cerebrospinal  meningitis,  568 

in  encephalitis  lethargies,  272 

in  poliomyelitis,  591 
Sponge  bath,  in  cerebrospinal  meningitis,  566 

in  grip,  217 

Sponges,  cold,  in  pneumonia,  161 
in  yellow  fever,  739 

cool,  in  chorea,  60 
in  dengue,  642 
in  measles,  494 
in  pertussis,  537 
in  typhoid  fever,  291 

Sponging,     cold,     for    bronchopneumonia    com- 
plicating measles,  496 

for  fever  in  measles,  494 
Spoons,  disinfection  of,  281 
Sporadic  influenza,  216,  and  see  Grip 
Spriggs,  on  excretion  of  creatinin,  23 
Sputum,  disinfection' of  in  typhoid  fever,  281 

typing  of,  in  pneumonia,  131 
Standard  portions,  Fisher's  tables  of,  17 
Starva^n,  18 ,  20,  29 

in  bacillary  dysentery.  363 
Steam  inhalations.    See  Inhalations,  steam 
Steak,  fo9d  value  of,  17 
Sterilization  after  scarlet  fever,  425,  442 
Stitt,  method  of  giving  quinine  in  malaria,  329 

on   treatment   of   hepatic   abscess   in   amebic 
dysentery,  379 

on  yellow  fever,  735 

Still,  on  urethane  for  convulsions  in  pertussis,  536 
Stimson,  on  rabies,  708 
Stomach,  hemorrhages  from  in  dengue,  643 

motility  of  in  acute  infectious  diseases,  18 
Stomach  tube,  in  diphtheria,  451 
Stomach  washing,  for  vomiting  in  typhoid  fever, 
694 

in  infectious  jaundice,  730 
Stomatitis,  in  pneumonia,  148 

in  varicella,  517,  519 
Stools,  in  acute  infectious  diseases,  21 

disinfection  of,  281 
Strapping  the  chest,  in  fibrinous  pleurisy,  114,  126 

in  pneumonia,  161 

Streptococcus    hemolyticus,    complicating    mea- 
sles, 489,  495,  502 
Streptococcus  empyema,  211,  and  see  Empyema, 

streptococcus  type 

Streptococcus   pneumonia,    208,    and   see   Pneu- 
monia, streptococcus 
Strong,  on  leprosy,  670 
Strophanthin,  in  acute  glanders  and  farcy,  692 

in  anaphylactic  shock  in  pneumonia,  145 

in  anthrax,  683 

in  bacillary  dysentery,  365,  373 

in  cerebrospinal  meningitis,  566 

in  cholera,  650 

in  febrile  conditions,  6,  9 

in  pneumonia,  145,  173,  178,  203 

in  pneumonia  of  epidemic  influenza,  247 

in   pulmonary   edema   of   epidemic   influenza, 
248,  267 


Strophant'iin,  in  septicemia,  762,  770 

in  scarlet  fever,  404,  434 

in  typhoid  fever,  299 
Strychnine,  in  anthrax,  683 

for  dyspnea  in  pneumonia,  179 

for  nervous  symptoms  of  malaria,  339 

in  cerebrospinal  meningitis,  566 

in  cholera,  650 

in  control  of  prostration  from  belladonna,  531 

in  convalescence  from  diphtheria,  474 
from  dengue,  643 
from  epidemic  influenza,  261 
from  infectious  jaundice,  733 
from  Malta  fever,  660 
from  measles,  502 
from  typhoid  fever,  303 

in  diphtheria,  470 

in  febrile  conditions,  6 

in  glandular  fever,  557 

in  grip,  225,  233 

in  pneumonia,  152 

in  poliomyelitis,  600 

in  scarlet  fever,  406,  435 

in  typhoid  fever,  299 

in  tympanites  of  epidemic  influenza,  252 
Stupes,  for  backache  in  yellow  fever,  738 

for  pain  in  bacillary  dysentery,  362 

for  pain  in  dengue,  642 

for  tympanites  in  epidemic  influenza,  251 

for  tympanites  in  typhoid  fever,  293 

in  cholera,  647 

in  pneumonia,  152 

turpentine,  preparation  of,  363 
Stupor,  in  measles,  494 

in  septicemia,  758,  761 

in  typhoid  fever,  317 

in  typhus  fever,  629 
Subglottic  edema  differentiated  from  laryngeal 

diphtheria,  464 
Sugar,  food  value  of,   17 

percentage  of  in  milk,  17 

Sulphates,  ethereal,  in  endogenous  metabolism,  23 
Sulphur  in  metabolism,  24,  26 
Sulphur  dioxide,  as  disinfectant,  616,  737 
Suspensory  for  orchitis  complicating  mumps,  549 
Symptomatic  treatment.     See  under  the  several 

diseases 

Symmers,  on  pneumonia  in  epidemic  influenza, 
236 

Tachycardia,  in  epidemic  influenza,  257,  269 

in  scarlet  fever,  403 
Tartar  emetic,  in  laryngitis,  98,  99 
Teeth,  care  of.     See  under  the  several  diseases 
Tender  toes  complicating  typhoid  fever,  302 
Tenesmus,  in  bacillary  dysentery,  363,  372 
Terpin  hydrate,  in  bronchitis  of  children,  108 
Testicle,  involvement  of  in  mumps,  549 
Tetanus,  711 

antiseptics  in,  722 

bed  in,  713.  724 

care  of  bladder  in,  714,  725 
of  body  in,  724 
of  bowels  in,  714,  724 
of  circulation  in,  721,  727 
of  mouth  in,  724 

causes  of  death  in,  721 

complicating  vaccination,  618 

diet  in,  713,  724 

drug  treatment  of,  718,  719,  720 

fluids  in,  724 

incubation  period  of,  711,  723 

local,  718 

local  treatment  of,  714,  718,  722,  725 

mortality  in,  721 

prodromata  of,  712 

prognosis  of,  721 

prophylaxis  of,  712,  727 

rest  in,  712 

retention  of  urine  in,  714,  725 

room  in,  713,  723 

specific  treatment  of,  714,  725 

summary  of  treatment  of,  723 

symptoms  of,  712,  723 


804 


INDEX 


Tetanus,  treatment  of  convulsions  in,  719,  726 

treatment  of  developed  form  of,  712 
Tetanus  antitoxin,  706,  722,  725,  727 

combined  intraspinal,  intravenous,  and  intra- 
muscular administration  of,  726 

dosage,  715,  716,  717,  722,  723 

intracerebral,  administration  of,  717,  725 

intramuscular  administration  of,  716,  717,  725, 
726 

intraneural  administration  of,  717,  725 

intraspinal  administratipn  of,  716,  725 

intravenous  administration  of,  716,  725 

prophylactic  use  of,  721,  727 

subcutaneous  administration  of,  715,  725 

unit  of,  715 

use  of,  715,  722 
Tetanus  ascendens,  711 

descendens,  711 
Theobromine,  as  diuretic  in  scarlatinal  nephritis, 

420 

Theocine,  in  pleurisy  with  effusion,  123 
Thermokinetic  energy,  11 
Thoracentesis,  in  empyema  in  pneumonia,  181 

in  pleurisy  with  effusion,  119,  127 

technique  of,  181 
Throat,  care  of.    See  under  the  several  diseases 

compress,  in  tonsillitis,  84 

examination  of  in  infections  in  childhood,  443 
Thrombophlebitis,    complicating   typhoid   fever, 
302 

in  septicemia,  762 

in  septicopyemia,  758 

Thromboplastin,  in  hemorrhage  of  typhoid  fever, 
296 

in  nosebleed  of  diphtheria,  467 
Thrombosis  of  pneumonia,    190,  206 
Thymus  gland  in  mumps,  550 
Ticks,  and  Rocky  mountain  spotted  fever,  664 
Tick  fever,  664  and  see  Rocky  mountain  spotted 

fever 

Tissue  destruction,  in  acute  infections,  450 
Tissue  metabolism,  creatinin  as  indicator  of,  23 
Tongue,  care  of,  in  pneumonia,  148 

in  scarlet  fever,  396 

in  small  pox,  610 

in  typhoid  fever,  280 

coated,  in  acute  infectious  diseases,  18 
Tonics,  in  convalescence  from  diphtheria,  474 

from  grip,  225,  233 

from  epidemic  influenza,  261 

from  infectious  jaundice,  733 

from  pertussis,  536 
Tonsillitis,  80 

adenitis  in,  86 

care  of  body  in,  83,  89 
care  of  bowels  in,  82,  88 
care  of  heart  in,  85 

chronic,  87,  91 

circulation  in,  85 

complications  in,  86 

convalescence  from,  87,  90 

cultures  in,  81 

diet  in,  82,  88 

differentiated  from  diphtheria,  80 

drinks  in,  82,  88 

drugs  in,  82,  89 

etiology  of.  80 

fever  in,  83,  89 

gargle  in.  84,  90 

in  epidemic  influenza,  256 

in  grip,  227,  233 

in  poliomyelitis,  597 

insomnia  in,  84,  89 

local  treatment  in,  84,  89 

nephritis  in,  86 

peritonsillar  abscess  in,  86 

precautionary  measures  in,  81 

and  rheumatism  in  childhood,  30 

septic  sore  throat  in,  85 

septicemia  in,  86 

sequelae  of,  86 

serum  therapy  in,  86 

summary  of  treatment  of,  83 

symptomatology  of,  81 


Tonsillitis,  throat  compress  in,  84 

toxemia  in,  85,  90 

treatment  of,  81 

urine,  examination  of,  85 
Tonsils,  80 

attention  to  in  bronchitis  of  children,  108,  111 

in  glandular  fever,  556 

in  rheumatism,  62 

removal  of,  indications  for,  88 
in  pertussis,  537 
in  pneumonia,  193 
Toxemia,  in  acute  infectious  diseases,  20 

caloric  intake  and,  28 

factor  in  feeding  in  infectious  diseases,  18 

factor  in  fever,  19 

hydrotherapy  aimed  at,  5 

in  glandular  fever,  556 

in  Malta  fever,  659 

in  pneumonia,  167 

in  tonsillitis,  85 

meaning  of,  757 

parallelism  of  with  pyrexia,  1 

tissue  destruction  due  to,  450 
Toxins,  453 

effect  on  nerve  centers  in  febrile  conditions,  5 

factor  in  nitrogen  loss  in  infectious  diseases, 

20 
Tracheitis,  101,  and  see  Bronchitis,  acute 

in  grip,  224,  232 
Tracheotomy,  in  diphtheria,  464 

in  edema  of  larynx,  99 

Transfusion  of  blood,  in  delayed  resolution  in 
influenza,  252 

in  erysipelas,  777 

in  hemorrhage  of  typhoid  fever,  297 

in  pneumonia,  in  epidemic  influenza,  252 

in  septicemia,  766 

methods  of,  767 
Trench  fever,  751 

aches  and  pains  in,  752,  754 

anemia  in,  752,  755 

bed  in,  752 

cardio-vascular  disturbances  in,  753,  754 

care  of  patient  in,  752 

carriers  of,  754 

catharsis  in,  752 

complications  of,  753 

convalescence  in,  753,  755 

delousing  in,  753 

diet  in,  752,  754 

disinfection  after,  753 

disposition  of  excretions  in,  752 
-   drinks  in,  752,  754 

fever  in.  752 

incubation  period  of,  751 

insomnia  in,  752,  755 

isolation  in,  752,  754 

louse  and,  751,  753 

mode  of  conveyance  of,  751,  753 

nervousness  in,  752,  755 

prognosis  of,  752 

prophylaxis  of,  753,  755 

rest  in,  752 

sequelae  of,  753,  755 

summary  of  treatment  of,  754 

symptomatology  of,  751 
Trional,  in  dengue,  643 

in  epidemic  influenza,  246 

in  measles,  495 

in  mumps,  551 

in  pertussis,  533 

in  pneumonia,  169 

in  poliomyelitis,  596 

in  rheumatism,  37,  68 

in  scarlet  fever,  407 

in  septicemia,  762 

in  small  pox,  614 

in  tonsillitis,  84.  89 

in  typhoid  fever,  298 
Trismus,  712 

Tuberculosis,    complicating    epidemic    influenza, 
255 

complicating  measles,  502 
Turkey,  food  value  of,  17 


INDEX 


805 


Turpentine,  in  bronchitis,  105,  109 
in  black  vomit  of  yellow  fever,  739 
in  laryngitis  complicating  measles,  499 
in  pneumonia,  152 
in  tracheitis  of  grip,  224 
in  tympanites  of  typhoid  fever,  293 
Turpentine  stupes,  for  pain  in  bacillary  dysentery, 

363 

in  pneumonia,  152 
preparation  of,  363 
Tympanites,  in  bronchopneumonia  complicating 

measles,  498 

in  epidemic  influenza,  251,  267 
in  pneumonia,  152,  199 
in  typhoid  fever,  292,  294,  314 
Tvphoid  fever,  277 
'bed  in,  279 
bedsores  in.  280,  310 
Brand  bath  in,  288 
care  of  alimentary  tract  in,  292,  314 

of  body  in,  280.  309 

of  bowels  in.  292,  314 

of  circulation  in,  298,  317 

of  teeth  in,  280 

of  tongue  in,  280 

of  urinary  tract  in,  300,  318 
carriers  of.  304,  319 
complications  of,  302,  318 
convalescence  from,  303,  318 
diet  in,  282.  311 
disinfection  in,  281,  310 
drinks  in,  314 
etiology  of,  277 
gastric  distress  in,  295,  315 
hemorrhage  in,  295,  316 
hydrotherapy  in,  287,  298,  314 
isolation  in,  304 
lipovaccines  in,  309 
meningismus  in,  302 
mortality  in,  277 

influence  of  hydrotherapy  on,  287 
open  air  treatment  of,  279 
packs  in,  291 
pathology  of,  277 
perforation  in,  297 
phlebitis  in,  302 
physiology  of  diet  in,  3 
precautions  for  nurse  in,  311 

for  physician  in,  311 
preventive  inoculation  for,  306,  319 
prophylaxis  from,  303,  319 
pulse  in,  290 
rest  in,  278 
revaccination  in,  308 
room  in,  279,  309 
slush  in,  291 
summary  of  treatment  in,  309 

rptomatology  of,  277 
•apy  of,  278 
treatment  of  cerebral  disturbances  in,  298,  316 

of  convalescence  in,  303,  319 

of  diarrhea  in,  294,  315 

of  hemorrhage  in,  296,  316 

of  tympanites  in,  292,  314 

of  vomiting  in,  295,  315 
use  of  alcohol  in,  299 
vaccine  therapy  in,  301,  318 
vomiting  in,  295,  315 
walking,  278 
water  in,  287 
Ziemssen's  bath  in,  291 
Typhoid  state,  300 
Typhus  fever,  625 
bed  in,  626 
care  of  body  in,  626,  627,  631 

of  bowels  in,  629,  632 

of  circulation  in,  629 

of  hair  in,  626 

of  mouth  and  nose  in,  628,  632 

of  patient  in,  627 

of  teeth  in,  628 
cardiac  weakness  in,  626 
complications  of,  630 
convalescence  from,  630,  633 


Typhus  fever,  diet  in,  628,  632 
disinfection  in,  626,  627,  631,  633 
incubation  period  of,  625 
isolation  in,  626,  631 
louse  and,  625,  626 
nervous  manifestations  in,  629 
onset  of,  625 

open  air  treatment  of,  630,  632 
otitis  complicating,  630 
parotitis  complicating,  630,  633 
prophylaxis  in,  631,  633 
room  in,  626,  631 
summary  of  treatment  of,  631 
treatment  of  constipation  and  meteorism  in, 
629 

of  delirium  in,  629,  632 

of  diarrhea  in,  630,  633 

of  edema  of  larynx  in,  630,  633 

of  fever  in,  628 

of  headache  in,  629 

of  laryngitis  in,  630 

of  nausea  and  vomiting  in,  629 

of  stupor  in,  632 

Ulcerative  stomatitis,  complicating  measles,  499, 
509 

in  varicella,  517 

Ulceration.  in  foot  and  mouth  disease,  695 
Ulcers,  in  bacillary  dysentery,  367,  373 

in  chronic  farcy,  688 

in  foot  and  mouth  disease,  695 

in  measles,  501 

in  pertussis,  554 

in  small  pox,  611.  612 
Undulating  fever,  656.  and  see  Malta  fever 
Unger.  on  olood  transfusion,  767 
Uremia,  in  cholera,  650 

in  diphtheria,  473 

in  scarlet  fever,  415 
Urea-forming  function,  25 
Urethane,  for  convulsions  in  pertussis,  536,  543 
Uric  acid,  in  endogenous  metabolism,  23 

excreted  by  kidneys  in  febrile  conditions,  22,  24 
Urinals,  disinfection  of,  281 

Urinary  tract,  care  of  in  typhoid  fever,  300,  318 
Urine,  bacteria  in,  in  typhoid  fever,  300 

creatin  in,  24 

disinfection  of,  281 

examination  of,  in  tonsillitis,  85 

Folin's  analysis  of,  22 

nitrogen  in,  22 

retention  of,  in  epidemic  influenza,  238 
in  Malta  fever,  658 
in  plague,  635 
in  poliomyelitis,  594 
in  tetanus,  714 
in  typhoid  fever,  300 

suppression  of,  in  yellow  fever,  739 

typing  of,  in  pneumonia,  132 
Urticaria,  complicating  rheumatism,  57 

due  to  antipyretics,  223 

due  to  diphtheria  antitoxin,  459 

due  to  quinine,  333 

due  to  salicylates,  40 

due  to  sensitization  in  pneumonia,  134,  135 

due  to  serum  in  pneumonia,  144 
Urotropin,  in  bacilluria  in  typhoid  fever,  300 

in  cerebrospinal  meningitis,  567 

in  poliomyelitis,  597 

Vaccination,  in  small  pox,  616 

complications  of,  618 

contraindications  to,  619 

general  symptoms  of,  618 

technique  of,  617 
Vaccination,   preventive  against  typhoid  fever, 

306,308 

Vaccine  therapy.  See  under  the  several  diseases 
Vaccinia  generalized,  following  vaccination,  619 
Vallet's  mass,  for  anemia  following  diphtheria, 

in  scarlatinal  nephritis,  423 
of  trench  fever,  755 
in  convalescence  from  measles,  502 


806 


INDEX 


Vallet's  mass,  from  glandular  fever,  557 

from  pertussis,  537 
Van  Noorden,  on  diet  for  adults,  416 

on  gastrointestinal  function,  18,  26 
Varicella,  515, 

care  of  bowels,  517,  519 
of  patient  in,  515,  518 
of  skin  in,  516,  518 

complications  of,  517,  519 

convalescence  from,  517-519 

corneal  ulcer  in,  519 

diet  in,  516,  518 

disinfection  in,  517,  519 

distribution  of  family  in,  515,  517 

nervous  symptoms  in,  517,  519 

precautions  lor  physician  in,  518 

quarantine  in,  517,  519 

room  in,  515 

stomatitis  in,  517,  519 

summary  of  treatment  of,  517 

treatment  of  fever  in,  517,  519 
Variola,  608,  and  see  Smallpox 
Vedder,  method  of  giving  quinine  in  malaria,  329 

on  emetine  in  amebic  dysentery,  377,  379 
Venesection,    for    pulmonary    edema    in    pneu- 
monia, 178 

in  uremia  in  scarlatinal  nephritis,  420 
Venous  thrombosis  complicating  rheumatism,  67 
Ventilation,  ill,  evils  of,  4 
Ventricles,  dilatation  of,  in  rheumatism,  54 

puncture  of,  in  cerebrospinal  meningitis,  576 
Veronal,  for  sleeplessness  in  pneumonia,  169 

for  sleeplessness  in  rheumatism,  37 
Vincent's  angina,  91 

care  of  teeth  in,  92,  93 

diagnosis  of,  91 

etiology  of,  91 

malnutrition  in,  92,  93 

removal  of  membrane  in,  92 

severe  cases  of,  92,  93 

summary  of  treatment  of,  92 

symptoms  of,  91 
Virus  fixe,  in  rabies,  703 
Vitamines,  27,  28 

fat  soluble  A,  27 

water  soluble  B,  27 

Voit's  figures  concerning  protein  needs,  14 
Vomiting.    See  under  the  several  diseases 

and  cardiac  involvement,  46 

from  antipyretics,  223 

from  salicylates,  46 
Vomitus,  disinfection  of,  281 
Vulva,  noma  of  complicating  measles,  500 
Vulvitis,  complicating  mumps,  550,  553 

Walking  typhoid,  278 

Ward,  on  puerperal  sepsis,  766 

Wasting,  in  typhoid  fever,  283 

Water.    See  Baths  and  under  the  several  diseases 
cold,  effects  of  in  febrile  conditions,  3,  4,  5,  9 
insufficiency  of,  in  infectious  diseases,  18 
intake  of,  in  infections,  3,  4 
locally  applied  in  febrile  conditions,  2 
needed  in  fever,  29 

Waldeyer's  ring,  80 

Wallach,  on  blood  typing  in  pneumonia,  131 

Warburg's  tincture,  in  malaria,  334 

Weaver,  on  scarlet  fever,  424 

on  dosage  of  diphtheria  antitoxin,  455 


Weaver,  on  vaccines  in  scarlet  fever,  407 

Wegeforth,  on  lumbar  puncture,  573 

Weight,  caloric?  requirements  and,  12 

Weight  rule,  for  dosage,  37 

Weil's  disease,  728,  and  see  Infectious  jaundice 

Welch,  on  use  of  human  serum,  768    . 

Wellman,  on  dosage  of  quinine  in  malaria,  329 

Western,  on  puerperal  sepsis,  765 

Weston,  on  vaccines  in  scarlatinal  otitis  media, 

411 

Wet  compress,  technique,  97 
Wherry,  on  prophylaxis  in  cholera,  651 
Whey,  food  value  of,  17 
White's  instructions  on  yellow  fever,  736 
Whoop,  in  whooping  cough,  521 
Whooping  cough,  520,  and  see  Pertussis 
Wickman,  on  types  of  poliomyelitis,  597 
Wintergreen,  oil  of,  43,  and  see  Salicylates 
Wolf  and  Lambert,  25 

on  pneumonia,  22 
Woolen    underclothing,    in    convalescence    from 

scarlatinal  nephritis,  423 
Wooley,  on  leprosy,  673 
Wool  sorter's  disease,  679,  and  see  Anthrax 
Wound,  treatment  of  in  rabies,  700,  708 

in  tetanus,  722 

Wright,    Sir   A.    E.,    preventive    inoculation    in 
typhoid  fever,  306 

X-ray  treatment  of  leprosy,  674 

Yellow  fever,  735 

backache  in,  738,  742 

bed  in,  737 

black  vomit  in,  739,  742 

blood  pressure  in,  735 

care  of  body  in,  738 
of  bowels  in,  738,  741 

cause  of,  735 

circulation  in,  739,  742 

congestion  of  kidneys  in,  739,  742 

convalescence  in,  740,  743 

diet  in,  737,  741 

drinks  in,  738,  741 

fever  in,  739,  742 

fumigation  in,  737 

gastric  distress  in,  738,  742 

headache  in,  738,  741 

isolation  in,  735,  741 

precautions  for  non-immunes  in,  740 
for  nurses  in,  737,  741 
for  physicians  in,  737,  741 
-  prophylaxis  in,  740,  743 

relief  of  black  vomit  in,  739 

rest  in,  737 

room  in,  736 

specific  treatment  of,  738 

summary  of  treatment  of,  741 

suppression  of  urine  in,  739 

symptoms  of,  735 

transmission  of,  735 

treatment  of  symptoms  in,  738,  741 
Yeo,  on  quinine  in  grip,  224 
Young's  rule  for  dosage,  37 

Zeiler's  method  of  using  ipecac  in  amebic  dysen- 
tery, 376 

Ziemssen's  bath,  in  typhoid  fever,  291 
Zingher,  on  human  serum  in  scarlet  fever,  408 


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OVERDUE. 


FEB  24  1933 

MAR    4  ,942 


LD  21-50m-l,'3J 


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OF 

~~ '"""  LIBRARY 


